Community Health Worker (Full Time)

GENERAL DESCRIPTION :

The Community Health Worker (CHW) is a part of an inter-disciplinary clinical care team at a health center who helps increase access to health services for people through outreach, encouraging engagement, education, and peer support.

SPECIFIC DUTIES AND JOB FUCTIONS :

• Review monthly outreach list for each covered Health Plan and develop a plan with assistance from supervisor for prioritized outreach following MCHN best practices workflow.
• Document all outreach attempts in documentation tool and provide results monthly to allow for aggregate reporting to Health Plans.
• Provide direct education or engagement with contacted patients or connect to other resources for education as appropriate based upon initial assessment.
• Assist in maintaining assigned patient panels with covered Health Plans including helping patients change their primary care provider and supporting the Center in removing patients that are not served by the Center from its panels
• For newly assigned patients, coordinate a graduated intensity outreach program to engage patient in care.
• Assist contacted members with completion of assessment and address triggered interventions
• Contact assigned Health Plan members identified as either high or inappropriate utilizers of the emergency department and assist with scheduling follow-up appointment(s) with PCP or other health care staff (Behavioral Health, Dentist) as soon as possible.
• Provide education, including after-hours contact information, and resources to these members to contact their PCP if they believe urgent services are needed. This provides the opportunity to address needs through the Health Center services.
• Utilize reports to prioritize patient outreach attempts to close gaps in care (e.g. missing preventive service, poor chronic disease outcome etc.).
• Facilitate scheduling of required visit / testing and eliminate barriers to care as appropriate.
• Conduct SDOH screening and assessment using tools identified to uncover individuals' needs and connect members with available community resources addressing, but not limited to, the SDOH
• Report the appropriate detailed documentation utilizing the patient tracking report
• Maintain confidentiality and follows HIPAA standards in safeguarding patient information.
• Educate patients in taking and documenting at home vitals such as blood pressure monitoring.
• Educate patients in the use of remote patient monitoring devices.
• Assist with collecting vital patient records from the Health Information Exchange (HIE)
• Attend community outreach events as determined by management to promote patient / community health and education
• Participate actively in regular supervisory and team meetings and training sessions
• Other duties assigned by management

KNOWLEDGE, SKILLS AND ABILITIES :

PERSONAL ATTRIBUTES :

QUALIFICATIONS :

MyCare Health Center is an Equal Opportunity Employer. Applicants will be considered for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, disability, or any other characteristics protected by applicable law.