Community Health Worker - Montgomery

About Sage Health

We believe all seniors regardless of means deserve concierge primary care & wellness, without the concierge fees. They’ve earned it.

Sage Health builds enriching neighborhood health centers that are easy to access, provide or arrange for all of our patients’ healthcare needs, and partner with Medicare Advantage plans that fully cover primary care. Unlike other physician practices, a Sage Health physician has a patient panel of 400 or less, and we collaborate with the best outcomes-oriented specialists and hospitals in each market. Because we are not a fee-for-service provider and manage patients within a global capitation budget provided by Medicare Advantage plans, our only concern and motivation is to keep our seniors healthy.

Sage Health is a destination for the best risk provider talent in the country who are building the new standard-bearing senior model for the United States.

About the role

What you'll do

• Ensure patient information remains secure and confidential.
• Develop a database of grant-funded and community resources, i.e., food banks, transportation, churches, etc.
• Participates in center and market interdisciplinary team meetings, i.e., Weekly Utilization Medical Cost Meeting
• Assist patients in applying for government and community assistance or additional support, i.e., Medicaid, energy assistance, etc.
• Provides concise and thorough documentation through progress notes, including progression and attainment of goals, referrals to internal and external agencies, and contact/involvement with the patient’s family.
• Support the members in improving their well-being by staying out of the hospital and attending regular visits to their primary physician via education, clinical resources, and/or membership follow-up.
• Support the members in ensuring the pick-up of their prescriptions by providing education, quality compliance, and membership follow-up.
• Acts as a liaison and advocate between the patient, family, physician, and facilities/agencies
• Proactively engage the members to manage their own health and healthcare decisions.
• Provide members with education on community resources and benefits.
• Listen actively, communicate with empathy, and respectfully gather information.
• Conduct outreach to encourage participation in health-related programs, services, and/or providers.
• Use methods that promote learning and positive behavior change.
• Use a variety of interactive teaching and coaching methods for different learning styles
• Perform other duties as assigned.

Qualifications

• Currently resides in the Sage Health Medical Center City/County
• Valid driver's license, car insurance, and access to an automobile
• Must be able to travel between multiple healthcare facilities, i.e., centers, hospitals, skilled nursing facilities, and patient homes.
• Ability to travel locally up to 90% of the time.
• Must have at least two years of experience within the community/city.
• Attain Community Heath Worker certification within one year of hire.
• Experience working with the needs of vulnerable populations.
• Excellent interpersonal, written, and verbal communication skills

• High School Diploma/GED
• Bilingual (English/Spanish) (read, write, and speak) preferred.
• Current Certification as a Community Health Worker by the State
• At least 5 years’ experience in the delivery of services that are resident-driven and work with families to address multiple issues in-home and/or community-based environment