Care Advocate - Care Delivery

The CHW is an integral part of the member’s care team and works closely with the clinicians and the clinical operations team. The CHW will support our Care Delivery program, using approved curriculum to build trust and promote health, while simultaneously driving the Community Health Integration (CHI) and Principal Illness Navigation (PIN) programs to bridge the gap between clinical care and social needs.

We are so excited to launch Wider Care+! We are a mission-driven team dedicated to stabilizing high-risk populations and ensuring that no one falls through the cracks of the healthcare system.

At Wider Care+, we don’t just provide a service; we provide a lifeline. Our work bridges the gap between clinical requirements and social stability, and your role is vital to achieving that balance.

Our mission is to integrate Case Management, Care Navigation, and Benefits Enrollment into one seamless layer of support. We focus on patients whose Social Determinants of Health (SDOH) are actively sabotaging their recovery.

• Principal Illness Navigation (PIN):
  Execute person-centered care plans for patients with serious, high-risk illnesses. Assist in monitoring and revising disease-specific plans, especially when frequent adjustments in medication or treatment regimens are required.
• Clinical Care Bridge:
  Act as the link between the patient and the billing practitioner. Support care coordination by managing provider availability, rescheduling, and providing post-hospital discharge support.
• SDOH Assessment & Goal Setting:
  Conduct person-centered assessments to understand the patient’s social and cultural context. Identify unmet social needs—such as food insecurity or housing instability—that impact the management of their serious condition and develop specific action plans to address them.
• System Navigation & Advocacy:
  Assist patients and caregivers in navigating the Pennsylvania healthcare landscape. Teach self-advocacy skills to help patients communicate effectively with specialists and coordinate transportation or telehealth access.
• Technical & Workflow Support:
  Support patient communication templates and automation. Coordinate with the tech team to set up workflows, handle technical troubleshooting, and update patient charts in the Case Management System (CMS) with precision.
• Resource Coordination:
  Refer patients to supportive services and community-based resources. Establish and maintain partnerships with local Pennsylvania organizations to bring targeted resources (legal aid, food assistance, etc.) to our members' attention.
• Behavioral & Social Support:
  Use motivational interviewing and capacity-building to help patients manage the stress of chronic illness. Provide tailored education to improve treatment adherence and offer emotional support to families and caregivers.
• CMS Compliance & Documentation:
  Maintain detailed logs of all interactions, including the amount of time spent and specific activities conducted. Ensure all documentation meets the standards required for Medicare clinical and social integration services.

• PA Locality:
  Safely and consistently drive to public places and member homes within a 50-mile radius in Pennsylvania.
• Remote Independence:
  Successfully work in a remote team environment with high independence and minimal oversight.
• Physical Presence:
  Frequently carry up to 30 pounds of supplies and stand/walk for the duration of home visits or member interactions.
• Digital Literacy:
  Ability to use a computer, tablet, and smartphone to update data in multiple secure systems with accuracy.

• Compliance:
  Be willing to complete and maintain all CMS-mandated training and state-applicable requirements, including competencies in interpersonal building, service coordination, and professional ethical conduct.
• Experience:
  
  Have 3+ years of relevant community outreach, facilitation, or healthcare experience. Experience navigating high-risk chronic conditions or complex care management is a major plus.
• Technical Savvy:
  Have strong computer skills and the ability to navigate web-based and app-based systems…