Community Health Worker

Community Health Worker

Requirements

• High School Diploma/G.E.D.
• 2 years’ experience, preferably in related area.
• Good communication skills.
• Ability to work as a team member.
• Competent computer keyboard, laptop maneuvering, competent in Windows platform Basic computer skills and database entry.
• Good organizational skills.
• Ability to handle difficult calls and maintain professional conduct.
• Willingness to be flexible with job responsibilities.
• Spanish-speaking a plus.

Responsibilities

• Provide intensive outreach efforts by conducting home visits or visits to other appropriate settings to an identified patient population.
• Establish relationships with patients/families and provide general support and encouragement.
• Conduct intake interviews with patients using established protocols and intake tools.
• Work with patients and their physicians to develop personal health action plans that are achievable.
• Assist patients in addressing challenges to care for transportation, language, family/social support.
• Assist patients with comprehension of health insurance eligibility, benefits and navigation.
• Schedule appointments and perform reminders for patients.
• Ensure appropriate resources are available for attending appointments.
• Follow-up with patients by letter, phone call, text or home visit on missed appointments or referrals.
• Educate patients on self-care, healthful living, setting and achieving goals, using/reinforcing SUHI’s clinical education protocols, APP’s evidence-based tools or other, evidence-based tools.
• Refer patients to community-based resources to adhere to physician recommendations.
• Alert APP clinical team on patient needs, concerns, and interests.
• Ensure continuity of care.
• Keep accurate records of patient contacts and document patient needs, action plans, and follow up needs in appropriate database or electronic medical record.
• Provide health education activities for identified health concerns such as Asthma, Diabetes, Hypertension and other chronic diseases.
• Provide informal counseling, education, and social support to assist patients with gaining access to continuous care and enabling services.
• Coach/encourage patient self-management and adherence to clinical recommendations for identified health concerns such as Asthma, Diabetes, Hypertension and other chronic diseases.
• Develop and maintain strong working relationships with external (e.g., referral sources and community agencies) and internal contacts (care team) through direct contact including participating in community meetings and care team huddles.
• Share information and resources, collaborate on initiatives and provide education to referral sources and community agencies to coordinate access to services.
• Collect and organize information to be used for current services and future community health education and outreach activities.
• Participate in care team huddles to understand and proactively respond to the needs of the patient population.
• In collaboration with the clinical team, identify, consolidate and manage a high-risk patient registry.
• Assist care team as needed and performs other duties as assigned.

Preferred Qualifications

• Spanish-speaking a plus