Community Health Worker

Responsibilities

• Find member populations that are difficult to locate (homeless, severe mental illnesses, substance use, medically underserved, in need of preventive services, etc.)
• Support members in improving their whole health through outreach and engagement activities, primarily field-based
• Enroll members into programs and services by effectively communicating their value
• Work with members to provide effective and efficient service coordination
• Collaborate and consult with Case Managers on clinical-based member care issues
• Provide on-site/in-home member assessments for safety risk, health needs, and barriers to care
• Develop service plans and guides with members and providers that include health management goals
• Engage with members, both in-person and on the phone, to achieve health management goals using health coaching, motivational interviewing, and problem-solving techniques
• Assist members in overcoming barriers to meeting health goals and update service plans accordingly
• Assist members in scheduling appointments and accessing community resources
• Assist MSW as needed
• Accompany, arrange for, or directly provide member transportation to health services appointments
• Follow up with members via phone calls, home visits, and visits to other settings where members can be found
• Work with social service agencies to arrange for other member needs (housing, food, clothing, financial assistance, etc.)
• Work with facilities to help transition members after discharge to a safe home environment
• Maintain accurate, quality, timely, and consistent documentation in the company database of member activities and interventions
• Achieve set goals/KPIs
• Continuously expand knowledge of community resources, services, and programs available to members and build ongoing relationships with these organizations to advocate for members
• Perform other duties as assigned

Requirements

• High School Diploma/GED required
• Bachelor’s Degree preferred
• Community Health Worker Certificate preferred, or at least a minimum of 2 years of experience working in health, social, or community services

Skills

• Knowledge of community resources within the community to be served
• Ability to represent the company with professionalism by maintaining clear professional boundaries with members and coworkers
• Working knowledge of social and health issues
• Ability to quickly establish credibility and trust with patients and build strong relationships
• Sound judgment and the ability to quickly analyze situations
• Ability to establish priorities and meet deadlines
• Ability to problem-solve in a proactive, creative manner
• Cultural competency—able to work with diverse groups of community members
• Technologically knowledgeable or experienced in note entry systems, smartphones, and laptops
• Experience providing peer support to patients with complex and multiple chronic conditions and challenging social and mental health conditions (e.g., Community Health Worker, Patient Navigator, In-Home Support Specialist, etc.)
• Training or experience in community health, social determinants of health, and peer counseling
• Training and experience in using Motivational Interviewing strongly preferred
• Strong interpersonal and social skills with demonstrated ability to collaborate with a variety of individuals from a wide range of professional and personal backgrounds
• Knowledge of community-based healthcare and social services systems and the needs of medically underserved populations, and older adults/seniors
• Ability to thrive in a complex and rapidly changing environment
• Maintains confidentiality and follows HIPAA standards in safeguarding patient information
• Good oral and written communication skills
• Knowledge and/or experience within Home Support Services (IHSS) is highly desirable
• Life experience overcoming the challenges of chronic disease or work experience with people living with complex chronic conditions is highly desirable
• Thrives in an unstructured, start-up environment
• Self-starter that can work independently and collaboratively, prioritize tasks, and has initiative and excitement to take on unfamiliar tasks
• Excellent communication and interpersonal skills with the ability to effectively communicate with all levels of management, patients, and family members
• Creative, flexible, well-organized, resourceful, and detail-oriented
• Excellent judgment in handling confidential and sensitive information
• Ability to work independently, set priorities, and handle multiple tasks with a high level of efficiency
• Ability to establish and maintain cooperative working relationships with others
• Bilingual (Spanish) preferred, but not required

Core Competencies

• Instills trust
• Customer focus
• Manages ambiguity
• Collaborates
• Drives results