Community Health Worker

2 weeks ago

Silver Spring, United States Medicalincs, LLC Full time

Community Health Worker (Washington DC)

The Community Health Worker (CHW) or Community Support Specialist (CSS) will serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. This involves collaboration and continuous partnership with client's staff, primary care practices practitioners & staff, their patients and their families/caregivers, clinic/hospital/ specialty providers, and community resources - in a patient-centered collaborative care environment. The CHW will build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy. The Lead Care Manager will provide clinical supervision and oversight of the CHW.

This is a staffing position and will report to the assigned Clinical Care Manager.

Responsibilities & competencies
- Promote timely access to appropriate care
- Increase utilization of preventive care
- Reduce emergency room utilization and hospital readmissions
- Increase comprehension through culturally and linguistically appropriate education
- Work with beneficiaries to plan and monitor care
- Assess beneficiaries’ unmet social needs
- Provide community resources to the beneficiaries to assist with food, housing, mobility, energy assistance, childcare, and other governmental programs
- Educate patient and family/caregiver(s) about relevant community resources
- Develop an intervention plan with the patient, family/caregiver(s) providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate) and Lead Care Manager
- Monitor adherence to intervention plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed
- Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the intervention plan regarding transitions-in-care and referrals
- Attend or call-in for daily and weekly rounds. Weekly rounds will include a review of all beneficiaries on CHW caseload and those in outreach (referred)
- Responsible for at least two outreach days in the community. Communicate with Care Team and Lead Care Manager to provide enrollment and progress updates
- Share beneficiary concerns with the Care team including, but not limited to, changes to social barriers, changes in schedule and rounds
- Notify the Lead Care Manager when a beneficiary has case management or additional assistance need.
- Complete home and hospital visits to assist with enrollment for CHW services and to improve participant engagement
- Attend clinical mandatory training to improve beneficiary communication and clinical skills
- Provide documentation, in preferred practice platform, detailing efforts, resources, and communications with beneficiaries
- Document patient progress and treatment recommendations in EHR and other required systems
- Facilitate referrals for social services such as food, housing, mobility, energy assistance, childcare, transportation, and other governmental programs
- Facilitate encounters between the patient, family/caregiver(s), care team, payers, and community resources, as needed
- Attend all MDPCP training courses/webinars and meetings
- Provide feedback for the improvement of the Health Services for Children with Special Needs Care Management Program
- Perform other duties as required.
- Success in this position will lead to improved physical and mental health for the patient and reduced health care costs for the managed population of patients.

QUALIFICATIONS
- High School Diploma or GED required
- Associate's Degree desirable
- 1-3 years’ experience working in community health care settings is required
- Local knowledge about and connections to community health care and social welfare resources is desirable
- Must have a strong team building, leadership, and mentoring skills
- Must have high organizational, performance management, and problem-solving skills
- Have high emotional intelligence and exceptional communication skills
- Must have influencing skills that foster a collaborative and continuous-improvement environment
- Proven ability to lead, motivate, and build cross-functional teams that deliver services and solutions that surpass client expectations
- Highly organized with the ability to keep accurate notes and records
- Experience with health IT systems and reports is desirable
- Must be customer/patient-focused
- Contribute to high-quality deliverables and/or tasks under supervision.

In addition to the above qualifications the successful incumbent is expected to consistently demonstrate:

- Core values consistent with a patient
- and family-centered approach to care
- Demonstrates professional, appropriate, effective, and tactful commun

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