Certified Community Health Worker - Center Health Equity

Do you believe everyone deserves the opportunity to achieve their best health? Join Tri Health's Center of Health Equity as a Certified Community Health Worker and help bridge the gap between healthcare and the communities we serve.

In this mission-driven role, you'll work directly with patients and families to address barriers to care, connect individuals with vital community resources, and support healthier outcomes. As a trusted advocate and partner, you'll help advance health equity by empowering patients, strengthening community connections, and ensuring access to the support needed to thrive.

• Tri Health Baldwin Corporate Offices

• Full-time position, 80-hours bi-weekly
• Shift varies
• Rotating weekend commitment
• No holiday or on-call commitments

We offer competitive shift differentials, opportunities for professional growth, and a comprehensive benefits package that may include medical, dental, vision, paid time off, retirement savings plans, and tuition reimbursement.

• High School Degree
• Basic Life Support for Healthcare Providers (BLS)
• Certified Community Health Worker
• Knowledge of priority neighborhoods
• Strong oral communication skills and interest in the health of patients and families

Functions as an integral part of the Ambulatory Care Management team to support patients with high risk of readmission and/or those with clinically complex chronic conditions. Under the supervision of a nurse or social worker, the Ambulatory Care Management-Community Health Worker provides care coordination and advocacy to patients, including outreach and engagement, linkage of the patient with resources (food, housing, transport, financial, community-based services) as well as linking the patient with care.

This position provides input into the client’s situation and action plan. Assists patients/families, staff and systems to achieve high quality, evidence-based, cost-effective, and patient-focused outcomes.

• Collaborates with the care team and serves as a resource to coordinate access to local community agencies and assists families and patients in accessing appropriate services to meet identified needs. Coordinates referrals for services and facilitates contact to community-based organizations on client's behalf, to achieve positive health outcomes. Interacts with clinical and medical personnel across all hospital inpatient and outpatient service lines to ensure collaboration across care settings and meaningful integration at transition points.
• Contributes to assessments, gathering information from the patient, family, and caregivers regarding the following: patient's level of functioning, environment, appropriateness and adequacy of support system related to illness and ability to cope. Reports information back to the multidisciplinary care team, and document interventions in patient record.
• Monitors patient's adherence to health improvement or treatment plan. Intervenes with patients and patient's representatives regarding emotional, behavioral, and financial barriers to current illness and/or disability. Conducts patient visits, provider visits and community-based visits as needed to ensure effective support and achievement of patient's goals.
• Coaches and motivates patients as directed, utilizing behavioral interviewing techniques to identify and address barriers to effective patient self-management of chronic conditions (i.e. education level, language barriers, etc.) and adherence to treatment recommendations.
• Participates in quality improvement initiatives; activities may include data collection, chart review, interdisciplinary collaboration, analysis of patient data and inter-professional staff meetings.

• Upon annual validation of skills, certified CHW will monitor vitals including pulse ox, blood pressure and heart rate when on home visit.
  
  This will be under the supervision of an RN.
• Serve as the bridge between clinic and community
• Conduct outreach and engagement activities
• Reinforce care plans established by RN and Social Worker
• Assist with appointment adherence
• Community resource navigation

Climbing - Occasionally
Concentrating - Frequently
Continuous Learning - Frequently
Hearing:
Conversation - Consistently
Hearing:
Other Sounds - Frequently
Interpersonal Communication - Consistently
Kneeling - Occasionally
Lifting