SLH Care Management Community Health Worker

About the Role

Provides care coordination and advocacy to patients, including outreach and engagement, development of the care plan, linkage of the patient with resources (food, housing, transport, financial, community-based services) as well as linking the patient with care.

Responsibilities

• Administers risk assessment or intake interviews with patients and/or families and records this assessment in the patient's medical record; assesses patient's level of functioning, environment, appropriateness and adequacy of support system related to illness and ability to cope.
• Analyzes client activities and integrates appropriate program activities/services; evaluates availability of community and governmental services and resources.
• Assists in determining relevant goals and abilities which could include vocational or housing goals.
• Assists with coordination and delivery of preventive health care programs or in coordination of housing or vocational placement.
• Coordinates any appropriate documentation (consents, assessment tools) to the staff or Electronic Health Record (EHR).
• Coordinates patient care activities with other members of the healthcare team, the patient, the patient's representatives, and community partners and makes referrals as appropriate.
• Coordinates patients' care, such as arranging rides, appointment reminders, obtaining medical records, communicating with specialty clinics, and care team consults.
• Intervenes with patients and patient's representatives regarding emotional, behavioral, and financial barriers to current illness and/or disability.
• Maintains patient records, including patient assessments, plans, interventions, patient/family involvement, outside agency communications, and interdisciplinary contacts.
• Monitors patient's adherence to health improvement or treatment plan.
• Prepares case reports; documents assessment, progress notes, and related information as required by Medicare, Medi-Cal, Title 22, and other mandated regulations according to Department standards; prepares correspondence regarding patient intake or follow-up.
• Pre-screens clients to determine health care/social service needs and communicates those needs to professional or paraprofessional personnel as necessary.
• Provides consultation and education to team members regarding patient/family (social determinants) issues and community resources.
• Screens for any barriers to care such as substance abuse, neglect, or housing.
• Serves as a resource and provides counseling and treatment related to Substance Abuse, palliative care, or end-of-life planning.
• Serves as a liaison between Alameda Health System and community groups by providing information concerning relevant health/social service/community-based programs in Alameda County.
• Serves as a resource and coordinates access to local community resources, effectively assisting families and patients in accessing appropriate resources to meet identified needs.
• Coordinates referrals for patients to community services and may contact those agencies/community-based organizations on clients' behalf.
• Identifies and connects patients to community resources that will assist them in achieving good health outcomes.
• Recruits volunteers to attend drug treatment programs at participating drug treatment centers.

Requirements

• High School Diploma or G.E.D.
• Three years of progressively responsible work experience in a community-based health care service capacity; or one year full-time experience in the class of Specialist Clerk or higher with AHS services performing similar duties, or the equivalent of two years of relevant full-time experience working in a community outreach program performing similar duties.
• Experience with Electronic Health Records (EHRs) and Case Management applications, e.g., Midas or 3M.
• Valid California driver's license.

Preferred Qualifications

• Bachelor's degree in a related field (health, social science, or a related field such as psychology or counseling) or an emergency technician program.
• One year working in a community outreach program performing duties such as intake, peer counseling, assessments, program screening, placement, and referral.