Community Health Worker

Duties and Responsibilities

• Must be comfortable completing visits independently and as a team in patients' homes.
• Perform 4–5 home visits per day to follow up on member's needs, assesses on patient's basic social and human needs.
• Educate patients on alternative to emergency room for non-emergent care; assist, train and coach patients to obtain, schedule and reschedule health care appointments; explore transportation options and provide tips and techniques to ensure follow-up with service providers.
• Makes home visits to patients to perform assessments on patient's basic social and human needs.
• Provides direct care in patients' homes related to vitals, lab testing and phlebotomy, if applicable.
• Communicates findings with providers and documents in EMR.
• Serves as patients' key contact with health care team and facilitates interpretation abilities when applicable.
• Supports transitional care management process.
• Identifies potential medical or behavioral health concerns and collaborates nurse practitioner (NP) and/or supervisor and other healthcare providers.
• In collaboration with care team coordinates the provision of services/care to meet the patient’s social and health needs.
• Provides assistance to patients, families and caregivers to access basic resources such as food and housing.
• Collaborates with other health professionals, including contacting primary care provider offices, care management staff and community social service agencies on behalf of the patient.
• Effectively collaborates with Management, Community Health Coordinators and Nurse Practitioners and fosters collaborative teamwork to ensure comprehensive, patient centered care.
• Prepares and participates in team meetings.
• Maintains appropriate written and oral communication and documents patient encounters and updates the EMR within established time frames.
• Oversight for supporting departmental HEDIS Measures.
• Cross trains with Community Health Coordinator role.
• Maintains patient confidentiality within legal and regulatory parameters.
• Other duties as assigned.

Qualifications

• High school diploma or equivalent.
• Two (2) years’ experience in providing direct patient care in the home.
• CPR certification or ability to obtain in 60 days from hire.
• Computer Literacy: Strong PC and Microsoft Office, including experience in Outlook and Electronic Medical Record (EMR) experience.
• Ability to work well in multidisciplinary team setting.
• Ability to perform basic medical assessments, including but not limited to blood pressure, finger sticks and pulse oximetry.
• Ability to communicate and relate to individuals and families of various ethnic and cultural backgrounds, ages and economic status.
• Self-motivated with Strong organizational, prioritization and time management skills.
• Bilingual in Spanish (read, write and speak).
• Must have access to reliable transportation. A personal vehicle, a valid and current driver’s license, and active auto insurance are required.
• Frequency of travel: daily.
• Compliant with State of RI immunization regulations for healthcare workers.