Field Based Community Health Worker - Oahu

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The Field Based Community Health Worker is responsible for assessment, planning and implementing care strategies that are individualized by patient and directed toward the most appropriate, least restrictive level of care. They also identify and initiate referrals for social service programs; including financial, psychosocial, community and state supportive services, and manage the care plan throughout the continuum of care as a single point of contact for the member.

The Field Based Community Health Worker also addresses social determinants of health such as transportation, housing, and food access; link to community supports.

If you reside on Oahu, Hawaii, you'll enjoy the flexibility to work remotely as you take on some tough challenges.

Monday through Friday, any 8-hour or 10-hour shift to be determined by the hiring manager between the hours of 7:00 am to 6:00 pm Hawaii Standard Time. This position is a field-based position with a home-based office. You will work from home when not in the field.

Honolulu and surrounding communities in Hawaii. Local travel up to 75% and mileage is reimbursed at current government rate.

• Engage members either face to face or over the phone to educate about their health
• Review available member service records and relevant documentation (e.g., utilization history, functional level, stratification information, current plan of care)
• Conduct comprehensive member assessment that includes bio-psychosocial, functional, and behavioral health needs
• Utilize interviewing techniques and active listening to collect and retain member information and incorporating responses as they are presented to complete assessment
• Identify when supplemental assessments are needed and conduct supplemental assessments
• Identify member service needs related to health concerns
• Identify urgent member situations and elevate to next level when necessary
• Engage member to participate in the assessment process and collaboratively develop plan of care based on their individual needs, preferences, and objectives with nursing oversight
• Work with members to develop healthcare goals and identify potential barriers to achieving healthcare goals
• Identify member support systems available and incorporate into plan of care
• Review plan benefits and identify appropriate programs and services based on health needs and benefits
• Integrate health care and service needs into a plan or recommendation for member care and service
• Work collaboratively with the interdisciplinary care team to ensure an integrated team approach
• Collaborate with member to create solutions to overcome barriers to achieving healthcare goals
• Collaborate with hospital case managers to decrease ER visits and decrease hospital readmission rate
• Identify relevant community resources available based on member needs
• Refer members to appropriate programs and services
• Facilitate member choice of preferred provider
• Provide informal counseling and social support resources
• Advocate for individuals and communities within the health and social service systems
• Moderate work experience within own function
• Some work is completed without established procedures
• Basic tasks are completed without review by others
• Supervision/guidance is required for higher level tasks
• Performs other duties as assigned

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

• High School Diploma/GED (or higher) OR 5+ years of equivalent community outreach work experience
• 1+ year field-based experience (medical, behavioral, or social work field)
• Intermediate computer…