Community Health Worker
2 weeks ago
Community health is about more than just vaccines and checkups. It’s about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We’re with you every step of the way, with the care you need for each of life’s chapters. At Neighborhood, we are Better Together._
- As a private, non-profit 501(C) (3) community health organization, we serve over 414,995 medical, dental, and behavioral health visits from more than 87,099 people annually. We do this in pursuit of our mission to improve the health and happiness of the communities we serve by providing quality care to all, regardless of situation or circumstance._
- We have been doing this since 1969 and it is our employees that make this mission a reality. Regardless of the role, our team focuses on being compassionate, having integrity, being professional, always collaborating, and consistently going above and beyond. If that sounds like an organization you want to be a part of, we would love to have you._
The Community Health Worker (CHW) will work with Enhanced Care Management (ECM) patients to improve their whole health through outreach and engagement activities by helping patients navigate/access community services/resources and adopt healthy behaviors. This position will serve as an integral component of the Street Medicine program, engaging and enrolling individuals experiencing unsheltered homelessness into ECM. Additionally, this role will encounter and manage a shifting landscape to meet the ECM needs of the homeless and underserved populations. The CHW will split their time between providing ECM services to patients in the community and in the clinical setting(50/50 split).
**Responsibilities**
- Maintains situational awareness and ensures scene safety when providing services in the community
- Conducts community outreach and establishes trusting relationships with patients while providing general support and encouragement
- Manages and provides ongoing follow-ups to an assigned caseload of patients including:
- Schedules patient appointments and encounter patients using EMR Registration program
- Uses basic motivational interviewing and goal setting
- Conducts phone calls, home or living environment visits, and visits to other settings where patients are located
- Assists patients attend appointments through assessing and addressing access barriers
- Provides referrals for services to community agencies as appropriate
- Assists patients connect with transportation resources and provides appointment reminders, as needed
- Conducts eligibility determination, enrollment, and follow up with uninsured patients
- Liaises between patients and community service agencies to ensure patient needs and rights are met, including collaborates with community providers to ensure continuity of care
- Assists patients in navigating the healthcare system by finding and following up by phone and in-person with eligible ECM patients
- Documents and shares patient barriers with ECM team and PCP to improve care and outcomes
- Utilizes evidence-based approaches when engaging with patients to increase their sense of control over their health, such as motivational interviewing to promote collaboration between patients and their medical/behavioral care team
- Communicates and delivers easy to read information about health and wellness to the community and provides information on ECM patient benefits and services
- Advocates on behalf of ECM patients in the home or their living environment to community and provider organizations
- Assists the ECM team and providers to understand the culture, norms, beliefs, and preferences about patients and their communities by representing the community's voice
- Helps create messages and materials that fit community culture and delivers messages to fit the culture of patients
- Works collaboratively within the ECM team to discuss responsibilities, task sharing, conflict resolution, and patient case reviews
- Collaborates on patient care issues with other ECM team patients
- Participates in weekly case reviews and consults with the patient's PCP before taking any clinical action
- Ensures documentation is accurate, helpful, and compliant with regulatory requirements and accreditation standards, including recording required documentation in eCW and managed care plans ECM portal within one day
- Participates in required staff meetings or other activities, as assigned
**Qualifications**
**Education/Experience**
- High school/GED required
- Valid BLS certification required upon hire
- Two years’ healthcare, behavioral health, street medicine, or social services industry experience required
- Experience working with unsheltered homeless and/or personal lived homelessness experience preferred
- Experience working in outreach and customer service within the medical office and behavioral health environments with individuals who struggle with subs
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