CHW Training Program

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* Summary:

** Reporting to the Director of Quality, this position is responsible for encouraging patient and provider shared decision-making, promoting healthy patient behaviors that reduce risk, improving medication adherence, furthering patient self-management skills and linking the clinical care provided by the Health Center with community –based social supports. Promotes the mission and philosophy of providing quality health care and related services to the medically underserved.

Upholds and ensures  compliance with all corporate policies and procedures, as well as the mission and values of the organization.
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* Primary Responsibilities:

** 1. Ensures all actions, job performance, personal conduct, and communications represent the organization in a highly professional manner at all times.  
2. Actively collaborate with other members of the primary care team including Care Managers, Support Staff and PCPs.  
3. Engage patients/families in the development/maintenance and activation of a comprehensive  treatment and self-management plan.  
4. Conducts Path (Personal Action Towards Health) Programs to patients, family members and members of the community.  
5. Provides linkages for services in community partner agencies to support patients/families social needs.  
6. Establishes trusting relationships with patients and their families while providing support, appropriate accountability, encouragement and outreach to patients.  
7. Address Social Determinants of Health (SDOH) issues identified during patient contacts and eliminate barriers to care as appropriate.  
8. Conducts comprehensive screening/assessment activities including health status, health risks and SDOH screening/assessment using tools identified by CFCN to uncover individuals needs and connecting members with available community resources addressing, but not limited to, the following SDOH: food, transportation, housing, economic stability, social & community connectedness, health & healthcare.  
9. Document all outreach to patients on appropriate reports and EHR.  10. Provides ongoing follow-up, motivational interviewing and goal setting with patients/families.  11. Address identified barriers to care that led to the utilization of ED rather than PCP.  12. Utilize individual reports to prioritize patient outreach attempts to close gaps in care.  13. Assists patient’s through the healthcare system including providing information for specialty appointments, contacting insurance companies regarding insurance coverage, DME suppliers and medical suppliers, etc.

on behalf of the patient.  14. Assists patients with identifying programs to assist with the cost of their health care needs by educating patients and/or their representatives about all eligible assistance programs. This includes evaluating eligibility requirements, assisting with the application process, and ensuring the patient can provide the required verification documentation. Seeks to minimize financial loss on behalf of CFC by enrolling patients in the most beneficial plan they are eligible for.  

15. Assists patients with enrollment in the Health Insurance Marketplace, Medicaid, Children’s Health Insurance Program (CHIP), CFC’s Sliding Fee Scale (SFS) Program, and any other available programs.  16. Duties may require travel to patients’ homes throughout CFCN’s service area, and occasional meetings or trainings within the State of Michigan. Travel expenses will be reimbursed.  17. Attends and successfully completes all required training programs, participates in staff meetings and ongoing training opportunities including but not limited to conference calls, webinars, and conferences to meet CEU requirements for MICHWA membership.  

18. Performs other duties as assigned.
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* Essential Job Functions:

** The demands described below are representative of those that must be met by an employee to successfully perform the essential functions of the job. The employee in this position must be able to perform the essential job functions of the position satisfactorily and, if requested, reasonable accommodations will be made to enable an employee with disabilities to perform the essential…