Community Specialist

Job Description

ESSENTIAL RESPONSIBILITIES / DUTIES :

• Initiates face to face contact with eligible patients to describe role, explain participation benefits and begin screening process.
• Schedules and completes initial hospital, clinic, or community-based (homes, shelters, housing agencies, substance use treatment programs, etc.) visit screening, care plan, and follow up visits and phone calls for enrolled patients within specified timeframes.
• Teaches key educational messages using a variety of culturally, linguistically and educationally appropriate strategies, in a variety of settings. Clearly documents all activities in the patient’s record and care management system.
• Participates with other staff in activities that include community outreach, presentations to community organizations, development of materials, and phone calls.
• Works with patients and providers to set goals for patient’s care and provides guidance for patient to achieve those goals.
• Reinforces educational messages regarding disease self-management by linking clients with supportive community services and programs.
• Presents patients at case review meetings succinctly and logically. Consults with RN / SW Care Manager, primary clinical staff, behavioral health teams and / or PCP regarding complex patient situations, demonstrating an understanding of how to solicit and incorporate provider feedback in order to continuously develop the most optimal plan for care.
• Demonstrates the ability to function within an inter-disciplinary team (nurse care coordinators, social workers, behavioral health clinicians, physicians, resource specialists, clinical support staff, etc.), connecting the patient with resources as needed.
• Records and monitors the participants’ progress toward goals within specific timeframes. Documents assessments and key patient updates in EMR system; documents relevant day-to-day activities and patient data.
• Prepares reports and documents as needed or requested.
• Assists patients with organizing their records, making follow-up appointments, attending follow-up appointments, and filling their prescriptions.
• Helps patients fill out applications, for example for Medical Assistance, Housing, and SNAP (Supplemental Nutrition Assistance Program).
• Provides advocacy, patient education and successful warm hand offs in accessing community-based and hospital-based programs.
• Assists patient in addressing and overcoming barriers with a range of concrete supports, including but not limited to : healthcare support services, behavioral health, financial assistance, child-care and caregiver support, housing, support with utility bills, food, financial entitlements, clothing, transportation, food pantries, violence prevention, social isolation and any other appropriate community resources.
• Provide intensive home and community-based outreach, motivational interviewing and goal setting, resource connection and accompaniment to medical appointments as needed to help patients appropriately utilize healthcare.
• CWAs may visit patients in hospital and ER settings to facilitate with transitions of care.
• Establishes culturally appropriate and trusting relationships with patients and their families.
• Participates in all training activities as designated by Community Wellness Manager (CWM).
• Attends regularly scheduled supervision and other program assigned meetings.
• Develops and maintains strong relationships with the community and community resources to ensure patient access.

NOTE : The CWA will not provide hands on care or other services noted as home health services, including but not limited to : performance assessments, provision of care, treatment, or counseling; and / or monitoring of patient’s health status.

EDUCATION :

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED :

EXPERIENCE :

KNOWLEDGE AND SKILLS :

Proficiency with Microsoft Office applications (i.e. MS Word, Excel, Access, Outlook) and web browsers. Proficiency with data entry and data tracking.