Community Health Worker

POSITION SUMMARY The Community Health Worker (CHW) will act as part of a Care Coordination Team under Charter Oak Health Center’s Patient Engagement Department. The department is designed to improve patient outcomes through intensive care coordination activities combined with solid quality improvement measures and patient participation. The overall goal is to improve our patient health outcomes. The CHW will engage in personalized, continuous contact with patients to engage them and drive them toward success with their care plans.

The CHW will call patients, meet with them face-to-face, track their progress, act as cheerleader in their successes, participate in interdisciplinary meetings, lead wellness activities, and connect patients to community resources.

Essential Position Duties Through cooperative efforts involving the patient on an intensive level, teach skills that will assist patients with overcoming the factors that may be influencing their current  a positive force in the lives of our patients, compassionately conveying the message to patients that many of the challenges will not be easy to overcome without significant patient commitment to making positive changes in their lives that will reduce the negative health conditions that they are experiencing.

Conduct interviews with patients to assess the social, behavioral and physical needs of our patients to be successful in attaining their goals.

Assist in developing comprehensive coordinated care plans for patients.

Maintain sustained contact with patient through phone calls, emails, texts, and in-person meetings.

Monitor patient progress in completing each of the steps on their care plan which may involve follow-up medical visits, meeting with specialists, nutrition, behavioral health or substance abuse counselling or assistance with finding shelter, food supports or any variety of aid that will help to stabilize and encourage them to make positive progress on their goals.

Review and analyze electronic medical records and other data to understand patient progress metrics and identify when it is necessary to reach out to patients for additional support.

Utilize electronic population database programs to track data and coordinate care.

Give support to patients in a non-medical environment, facilitating patient interaction with others in the community in a healthy endeavor.

Offer community resources to all engaged patients.

Appropriately refer patients to community resources and other organizations and be actively involved in making connections and following up with patients.

Compile records and prepares and submits reports as requested.

Participate in the interdisciplinary care coordination team and functions in multiple locations or in the community.

Attend regular program administration meetings.

Comply with the agency’s Mission Perform miscellaneous duties as required by management.

Maintain appropriate attendance.

Compliance Responsibilities Comply with applicable legal requirements, standards, policies and procedures including but not limited those within the Compliance Process, Code of Conduct, and HIPAA.Participate in required orientation and training programs, as required.

Report concerns and suspected incidences of non-compliance in accordance with COHC Compliance Reporting Process.

Cooperate with monitoring and audit functions and investigations.

Participate, as requested, in process improvement responsibilities.

POSITION QUALIFICATIONS Core Competencies/Skill Sets Must have experience working with a diverse population and must be culturally competent.

Behavioral Health background preferred.

Knowledge of local and regional health and social service resources.

Bilingual English/Spanish preferred.

Professional Experience/Educational Requirements High School Diploma Two years of human service experience preferred.