Community Health Worker

Community Health Worker

The Community Health Worker (CHW) works closely with medical providers, primary care teams, and social services agencies to provide short term care coordination. The CHW assists with connection to resources and support to program patients to improve their health and general well-being through education and provision of coordination of care and services. Community outreach, such as home visits, health screenings and events may be required.

This position reports to the Director, Patient Centered Services & Outreach and Co-Director of Patient and Community Engagement. No other positions report to this position.

While living and demonstrating our Core Values, the Community Health Worker will:

• Understand what it means to be the following: A Federally Qualified Healthcare Center (FQHC), A Patient Centered Medical Home (PCMH), Recognized as a National Committee for Quality Assurance (NCQA), Participant in an Accountable Care Organization (ACO)
• Assist patients in their homes, community, or health center setting
• Communicate to patients the purposes of the program and the impact it may have on their wellbeing
• Help patients identify socio-economic issues that affect their overall health and develop health/social management plans and goals
• Document patient encounters and contacts made on behalf of patients in EMR; completes and submits monthly reports; maintains comprehensive electronic patient files, which include patient notes, release of information, assessments and other medical documents acquired on behalf of the patient.
• Educate patients on the proper use of the Emergency Department and provide information for alternatives. Coach patients in effective management of their chronic health conditions and self-care. Assists patient in understanding care plans and instructions
• Motivate patients to be active and engaged participants in their health and overall wellbeing. Connects with Hot spotting Teams to connect patients with enabling services
• Provide support and advocacy during initial medical visit or when necessary to assure patients' medical needs and referrals required are being conveyed. Follow up with both patients and providers regarding health/social services plans. May be required to go to hospital as needed.
• Continuously expand knowledge and understanding of community resources and services Facilitate patient access to community resources, including locating housing, food, clothing, prenatal classes, parenting, and relevant mental health services. Assist patients in utilizing community services, including scheduling appointments with social services agencies and assisting with completion of applications for programs for which they may be eligible
• Facilitate communication and coordinate services between providers and the patients. Coordinate and monitor services, including comprehensive tracking of patients' compliance in relation to care plan objectives
• Work collaboratively and effectively within a team. Establishes positive, supportive relationships with participants and provides feedback to other members of the team. Build and maintain positive working relationships with the patients, providers, care managers, medical residents, and office staff. Work to reduce cultural and socio-economic barriers between patients and institutions
• Provide self-pay patients with options to pay for services
• Ensure patients understand health center resources and available programs, such as Sliding fee discount program, Good Faith Estimate (GFE), Outreach & Enrollment programs, Language services, After hours coverage
• Ensure compliance in the following areas:
  Availability and location of SDS binder, Availability and location 990 binders for all TWC entities, Understanding role and…