Community Health Worker, Hospital Care Transition Program

Rhode Island Parent Information Network, Inc.

Job Posting Community Health Worker, Hospital Care Transition Initiative Salary Range: $20 - 22 /hour About RIPIN: RIPIN deploys a peer model to support people with special healthcare and education needs across the whole lifespan. Founded in 1991 by a group of parents of children with special needs, RIPIN continues to be peer-led: a majority of our board and more than three-fourths of our staff are parents or caretakers of loved ones with special needs.

RIPIN’s peer professionals now help more than 45,000 Rhode Islanders every year navigate healthcare, schools, and other support systems.

Job Summary:

The Community Health Worker (CHW) is a peer who has experience in navigating Rhode Island’s health system for themselves, a family member or through previous employment. This CHW will work in RIPIN’s Hospital Care Transition Program, which supports Rhode Islanders who may be good candidates to discharge from the hospital back to their homes or other community settings but need a little extra assistance to make that possible.

The CHW will be a critical part of a comprehensive team providing options counseling, resources and referrals for post-hospital care. CHWs will engage with consumers in hospital settings providing person centered, culturally sensitive support, and building on the values, strengths and preferences of the patient. The CHW will also serve as an effective role model and mentor.

Essential Functions:

Assist patients and families in understanding and accessing informal and formal options for post-discharge care benefits including copay and cost of care.

Review and educate on benefits and eligibility for Medicaid Fee-For-Service, Medicaid/Medicare Managed Care, Medicare Advantage Plans, and any available private insurances.

Assist the consumer in completion and submission of enrollment or benefit applications. Refer consumers to other services and public or private agencies for additional supports as needed.

Utilizing motivational interviewing skills and culturally sensitive methods to collaborate with patients to explore preferred post-discharge supports and identify social determinants of health and/or areas of need within their community environment.

Review care options including natural supports, home care services, medical equipment, adult day health programs, senior centers and assisted living communities.

Coordinate with hospital discharge and health plan staff to enable post-discharge home and community supports to be established in a timely manner.

Assist consumers as they transition to independence/case closure by engaging with consumers and providing follow up support.

Maintain timely, accurate records, documentation, and reports as required.

Actively participate and complete training and professional development activities.

Assist in statewide system analysis, planning and coordination with state agencies, state and local boards, community-based organizations, and community rehabilitation programs.

Accept other duties and responsibilities as assigned.

Knowledge, Skills and Abilities:

Ability to demonstrate sensitivity towards, relate to, form trusting connections with, and motivate consumers as a peer mentor and to address barriers to care, health and wellness

Knowledge of Rhode Island health systems, terminology, supports, and services

Demonstrated ability and skill to work collaboratively with co-workers, consumers, families, service providers, and health plans, etc.

Skilled and/or willingness to learn and initiate motivational interviewing techniques with consumers

Demonstrated prior success in accessing community-based resources in Rhode Island Strong written and oral communication skills

Excellent organizational skills to manage…