Job Description

The Community Health Worker, HCT is a vital HCT member, who will use a strong knowledge of the local community to help engage patients in our primary care model, deepening the patient relationship with us and the patient's understanding of their plan of care. The incumbent will facilitate visits with our physicians through video during these community visits. The Community Health Worker, HCT will also use telephonic outreach to ensure patients are doing well after hospital discharge and during other times of increased medical risk to the patients. The incumbent will work closely with our nurse care managers and social workers to support a multidisciplinary approach to meeting our most complex patients' medical and social needs. Additionally, the incumbent will also support the HCT with patient scheduling and other tasks as determined by the team leaders. Essential job duties/responsibilities include assisting patients in their homes with telehealth visits with their Primary Care Physicians; working with patients assigned to us, but not actively engaged in care to link them to our physicians with the goal of full engagement in our model of care; assessing patient need for transportation to and from the appointment and coordinating with centers to schedule or assist patients with their health plan transportation policy for specialty appointments outside our centers; linking patient and family with community resources when necessary, including assistance with patient and family on completion of a Medicaid Application and other application for programs for which they may be eligible; performing discharge phone calls within 24-72 hours post discharge from inpatient setting using post discharge script explaining our services and obtaining consent for visits and upload to patient's chart; communicating between patient and discharge champion in the center to assure patient has 4-day post discharge appointment to see their Primary Care Physician (PCP); working collaboratively and effectively within the team of Community Nurse and Community Social Worker on their individual visit schedule, maintaining great communication with Nurse and Social Worker while maintaining their schedule and calendar; coaching patients in effective management of their chronic health conditions and self-care; motivating patients to be active, engaged participants in their health; continuously expanding knowledge and understanding of community resources, services and programs provided; attending meetings and reporting on patients as assigned; performing other duties as assigned and modified at manager’s discretion. Knowledge, skills and abilities required include competent-level business acuity; comprehensive knowledge and understanding of general/core job-related functions, practices, processes, procedures, techniques and methods; strong interpersonal and communication skills and ability to work effectively with a wide range of people in a diverse community with values of Love, Accountability and Passion; ability to work autonomously; strong time management skills and ability to prioritize patient visits and tasks; comfort working in fast-paced setting with a willingness to adapt to change; proficient in Microsoft office suite products including Word, Excel, PowerPoint and Outlook database and presentation software; ability and willingness to travel locally to patient homes up to 50% of the time; spoken and written fluency in English (bilingual preferred). Education and experience criteria include High School diploma or equivalent required; experience working with geriatric patients is a plus; established track record of excellent data management skills; a minimum of 2 years working in healthcare setting with patient-facing responsibilities; a minimum of 2 years working directly with primary care physician in an outpatient setting is preferred; any combination of three (3) years health/social services experience and/or education; possession and maintenance of a current, valid drivers license; Basic Life Support (BLS) certification from the American Heart Association (AMA) or American Red Cross required within first 90 days of employment.

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