Community Health Worker (Clinical)

Description

Summary: 

The Community Health Worker (CHW) serves as a health advocate helping patients and their families navigate and access community services. The CHW supports Providers and Care Coordination through an integrated approach to care management and outreach. Additionally, he/she will provide social support, promote education and perform informal counseling as well as advocate for individual and community health needs, and provide services such as home visits as required.

Essential Duties and Responsibilities:

Coordination of Care

• Provide follow up to provider appointments and encourage treatment plans set forth by the provider.

• Track patients who are being discharged from nursing homes or rehab facilities to ensure all of the patient needs are met. 

• Work closely with medical and behavioral health providers as well as Care Coordination to ensure patents have comprehensive and coordinated care.  

• Communicate with the ordering provider or staff regarding any updates, patient progress, and/or concerns.

• Meet compliance standards for documentation related to patient care and actions taken.

• Work cooperatively with non-clinical and clinical staff assigned to patients including being available for “warm hand offs” of patients

• Assist Care Coordination with regard to grants and special programs created to improve the health of patients.  This may include communication with patients and tracking of blood pressures, blood glucose results, mental health and memory issues.

• Schedules home visits that are deemed safe and considered reasonable. The CHW is not permitted to enter any home that could potentially put his/her life or wellness in jeopardy. The home must be sanitary for the CHW to enter. The purpose of a home visit is to assess for additional resources the patient could benefit from and to gather information for the provider or one who is requesting CHW sources. 

• Makes outbound calls to patients to provide assistance in obtaining services and  schedule appointments based on lists of targeted initiatives (value based contracts, QI initiatives, PI programs)

• Participate in specific community events as determined by the needs of the office.

Resource Navigation

• Contact patients regarding results from social determinants of health screenings and provide ongoing follow up, basic motivational interviewing and goal setting with patients/families. 

• Created patient driven action plans based on needs identified by clinic staff, screening tools or patient report

• Assist patients with completion of applications/forms, including advanced directives and MOLST/POLST forms as needed.

• Provide a link to community services and resources as appropriate and approved by the provider, including MAPs and AERs referrals.

• Maintain current and accurate knowledge regarding community resources appropriate for the needs of patients and families.

• Transports patients if an unplanned/unexpected need is identified by the PCP or clinical staff
   

 Core Values Statement

Qualifications

Qualifications:

The ability to initiate and maintain a positive working relationship with MLMC staff and other organizations is essential. Demonstrated work record showing good attendance, punctuality, dependability and the ability to work as member of a team with supervisors, providers and other co-workers and to work with the public and medical community at large in an appropriate professional manner.  The Community Health Worker must demonstrate compassion for those served by MLMC and be sensitive to the many and varied physical, emotional and cultural issues affecting the patient’s well-being.

Education/Experience:

• A high school diploma plus three (3) years related experience and/or training or equivalent is necessary, preferably in a medical related setting. A combination of education and experience will be considered.

• Successfully completed the Community Health Worker formal training program or be willing to complete this training. 

• Experience working in a community-based setting for at least two (2) years is preferred.

• Valid driver’s license and good driving record are required.

Understanding of HealthCare laws and Regulations:

Must have the ability to follow HIPAA guidelines as well as an understanding of policies and procedures regarding medical records put in place by the Federal Government; the willingness to learn complex federal and state regulatory guidelines for the many programs and services needed by the patients of MLMC.

Computer Literacy:
Extensive knowledge of computer software and proficiency in or knowledge of Microsoft Office programs such as: Excel and Microsoft Word. In addition, the Services Coordinator must have excellent computer skills and proficient knowledge and the use of electronic health records;

Reasoning Ability:

Must be able to demonstrate the ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Team Work:

An essential element is the ability to work and interact effectively and positively with other staff members to build and enhance teamwork in a patient centered team based model of care and in the overall MLMC organization; team engagement is a must to be successful in this position.

Work Record:

A demonstrated work record showing good attendance, punctuality, dependability and the ability to work well with supervisors and coworkers as part of a team effort is essential.  A medical office setting is an environment that requires the ability to relate to all types of people while always maintaining a professional demeanor.

Language Skills:

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals is essential. Ability to write routine reports and correspondence, and the ability to speak effectively to patients, co-workers and the public at large is paramount.

Sensitivity to Needs of Special Populations:

Must be able to demonstrate an understanding and sensitivity to cultural differences and needs of MLMC patients and be able to respond appropriately to all people regardless of race, ethnicity, language, age, sex or sexual orientation, religion, disability, economic standing, etc.

Physical Demands:

The work environment is a typical outpatient medical clinic.  While performing the duties of this job, candidates may be required to drive, sit for extended periods, spend time standing and walking, handle considerable paperwork, operate computers, lift up to 15 pound boxes of supplies and assist patients who may have limited mobility.

Work Environment:

Work is performed in a typical, outpatient clinic environment and in patient’s home if needed for their care. Home visits will likely account for several hours of the Community Health Worker’s week. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job.