Community Health Worker

This is a DIRECT-HIRE opening with a healthcare organization that focuses on offering a multidisciplinary primary care program to the Hispanic senior population.

* Must be Bilingual - Fluent in English and Spanish *

• Provides comprehensive care coordination to an assigned patient caseload.
• Works collaboratively with patients, family, caregivers, healthcare providers, and external partners, to meet complex social needs.
• Promotes a collaborative process and communication between all health care team members, internal multidisciplinary teams, inclusive patients/clients, families, and caregivers to ensure the process of integrated care services are targeted, appropriate, and beneficial.
• Intervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disability.
• Accesses and mobilizes family/community resources to meet social care needs.
• Documents all interventions in the patient medical record both timely and accurately including all elements of clinic visits, in home, telephonic engagement, or texting.
• Onboards patients to the organization's model and their medical/social care visits.
• Provides patient education on acute and chronic disease management.
• Provides guidance to patients and families.
• Establishes healing relationships with patients and families.
• Employs confidence-promoting techniques in patient communication and develops patient self-efficacy to better manage health.
• Communicates with patients in-person and by phone, video conference, and text messaging.
• Collaborates with other members of the multidisciplinary care team including but not limited to your manager, Transitions of Care managers, and Medicaid case managers
• Maintains knowledge of Medicare, Medicaid, and other program benefits to assist patients with resource allocation and choices.
• Provides consultation and collaborates with other team members on patients with significant or intensive community resources needs.
• Assists with the coordination of care across the continuum, such as: scheduling appointments with providers, coordinating referrals, and sharing or transferring information with the patient’s internal and external care team.
• Participates broadly in the daily operations of a primary care practice, such as:
  Answering incoming phone calls and messages and ensuring general upkeep of the clinical space.
• Tracks patient enrollment and progression through care programs
• Other duties as assigned by the Manager

• 4-5 years of experience working in healthcare setting or relevant experience
• Expertise connecting patients and ensuring closed loop referral with community resources and governmental agencies that address complex social needs
• Experience completing benefit applications such as SNAP, LIS, PAP, and prescription assistance
• High School Diploma/GED
• EMR Experience
• Community Health Worker (CHW) Certification preferred