Community Health Worker

We're unique. You should be, too.

We're changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy?

We're different than most primary care providers. We're rapidly expanding and we need great people to join our team.

The Social Complex Coordinator, CHW is a vital HCT member who will use strong local community knowledge to help engage patients in our primary care model, deepening the patient relationship with us and the patient's understanding of their care plan. The incumbent will facilitate visits with our physicians through video during these community visits. The Social Complex Coordinator, CHW, Complex Care will also use telephonic outreach to ensure patients are doing well after hospital discharge and during other times of increased medical risk to the patients.

The incumbent will work closely with our nurse care managers and social workers to support a multidisciplinary approach to meeting our most complex patients' medical and social needs. The incumbent will also help the HCT with patient scheduling and other tasks as determined by the team leaders.

• Assists patients in their homes with telehealth visits with their Primary Care Physicians
• Works with patients assigned to us who are not actively engaged in care to link them to our physicians with the goal of full engagement in our model of care.
• Assesses patient need for transportation to and from appointments with primary providers. Coordinates with centers to schedule or assist patients with transportation for specialty appointments outside our centers based on their health plan policies.
• Assists patients and families with connecting to community resources, including help with applications for eligible programs such as Medicaid.
• Performs discharge phone calls within 24-72 hours post-discharge from the inpatient setting. (Hospital, SNF, Long Term Acute Care Hospital (LTACH) using post-discharge script explaining our services and obtaining consent for visits and uploading to patient's chart.
• Communicate between the patient and discharge champion in the center to ensure the patient has a 4-day post-discharge appointment to see their Primary Care Physician (PCP).
• Works collaboratively and effectively within the team of Community Nurses and Community Social Workers on their visit schedule, maintaining excellent communication with Nurses and Social Workers while maintaining their schedule and calendar.
• Coaches patients in effective management of their chronic health conditions and self-care
• Motivates patients to be active, engaged participants in their health.
• Continuously expands knowledge and understanding of community resources, services, and programs provided; human relations and the procedures used in dealing with the public as part of a service or program; volunteer resources and the practices associated with using volunteers, operations, functions, policies, and procedures associated with the department or program area, procedures, and resources available to handle new, unusual, or different situations.
• Attends meetings and reports on patients as assigned.
• Performs other duties as assigned and modified at the manager's discretion.

• Competent-level business acuity
• Comprehensive knowledge and understanding of general/core job-related functions, practices, processes, procedures, techniques and methods
• Strong interpersonal and communication skills and ability to work effectively with a wide range of people in a diverse community with our values of Love, Accountability and Passion.
• Ability to work autonomously.
• Strong time management skills and ability to prioritize patient visits and tasks.
• Comfort working in fast-paced setting with a willingness to adapt to change.
• Proficient in Microsoft office suite products including Word, Excel, PowerPoint and Outlook database and presentation software.
• Ability and willingness to travel locally to patient homes up to 50% of the time.
• Spoken and written fluency in English (bilingual preferred)

• High School diploma or equivalent required.
• Experience working with geriatric patients is a plus.
• Established a track record of excellent data management skills.
• A minimum of 2 years working in a healthcare setting with patient-facing responsibilities.
• A minimum of 2 years working directly with a primary care…