Integrated Care Team - Community Health Worker

Position Summary

The ICT Community Health Worker plays a pivotal role in supporting care coordination functions, including HRSN screening and follow-up, patient engagement, and transitions of care management.

Job Responsibilities and Performance Standards

• HRSN Screening and follow-up Management:
  • Further assess and formulate a plan of care for patients screening positive for Health Related Social Needs (HRSN).
  • Implement the plan of care, including providing health education, facilitating access to needed services.
  • Monitor patient progress over time, make referrals to service providers, and coordinate care as needed.
  • Communicate patient updates to the ICT team and modify the plan of care as needed.
  • Complete necessary documentation, such as utility assistance, SNAP, disability, SSI, DTA, housing.
• Engagement:
  • Establish trusting relationships with patients to facilitate their connection to the primary care team.
  • Implement patient engagement strategies for hard-to-reach patients and those with barriers to primary care access.
  • Conduct home visits and accompany patients to appointments as needed to ensure compliance.
  • Update ICT on outcomes of engagement strategies and follow up on referrals from the population health team.
  • Refer clients to outreach and enrollment for health insurance coverage.
  • Follow up on warm handoff referrals from care management for patients requiring additional care coordination beyond the acute phase.
• Transitions of Care:
  • Follow up on patient referrals generated by the central population health TOC team to ensure post-discharge risk mitigation strategies.
  • Escalate to the primary care team any barriers affecting potential re-admission or preventable ED utilization.
  • Provide updates to the integrated care team regarding provider transitions of care, participate in pre-visit planning activities, and engage patients between visits.
  • Support efforts to meet identified key performance indicators and quality metrics; participate in quality improvement efforts.
  • Use motivational interviewing, harm reduction, and strengths-based approaches to support members in achieving stated goals.

Qualifications and Experience

• Community Health Worker Certification required, including a commitment to obtain certification within 6 months of hire.
• CPR Certified.
• Bilingual English/Spanish speaking preferred.
• Working knowledge of community resources and ability to assess and implement based on assessment.
• Effective problem-solving and critical thinking skills, including need for escalation.
• Demonstrated success in working as part of a multi-disciplinary team.
• Experience working with patients with chronic medical and behavioral health needs.
• Demonstrated experience working with diverse patient populations and workforce.
• Flexible and adaptable to change.
• Strong organizational skills with ability to prioritize, multi-task, and independently manage work demands, including escalation to supervisor when needed.
• Excellent interpersonal communication and written skills.
• Desirable qualities include enthusiasm and passion for helping patients in a non-judgmental and empathetic nature.
• Demonstrate the basics of cultural competence when dealing with a diverse population.
• Valid driver's license and access to reliable transportation.
• Working knowledge of Microsoft Office: Word, Excel, and PowerPoint.
• Willingness to learn and utilize telehealth technologies (video, chat) for various services.
• Ability to travel to patients' homes and in the community as needed, based on patient's needs.

Benefits

#GLFHC offers a great working environment, comprehensive benefit package, growth opportunities, and tuition reimbursement.