Community Health Worker

Position Status

Open

Site

Northeast Pennsylvania

NHC Position Type

Care Coordinator

Position Summary

Working  under the direction of  medical providers, primary care teams, and social services agencies, the Community Health Worker (CHW) will provide short term care coordination and connection to resources and support to program patients to improve their health and general well-being through education and provision of coordination of care and services. Community outreach, such as home visits, health screenings and events may be required. The CHW will be essential in helping patients alleviate health disparities brought on by the pandemic.

 

Major Duties and Responsibilities

  • Assist patients in their homes, community, or clinic setting
  • Communicate to patients/patients the purposes of care coordination and the impact it may have on their wellbeing
  • Help patients identify socio-economic issues that affect their overall health and develop health/social management plans and goals
  • Document patient encounters and contacts made on behalf of patients in EMR; completes and submits monthly reports; maintains comprehensive electronic patient files, which include patient notes, release of information, assessments and other medical documents acquired on behalf of the patient
  • Educate patient on the proper use of the Emergency Department and provides information for alternatives. Coaches patients in effective management of their chronic health conditions and self-care. Assists patient in understanding care plans and instructions
  • Motivate patients/patients to be active and engaged participants in their health and overall wellbeing. Connects with Hot spotting Teams to connect patients with enabling services
  • Provide support and advocacy during initial medical visit or when necessary to assure patients' medical needs and referrals required are being conveyed. Follow up with both patients and providers regarding health/social services plans.  May be required to go to hospital as needed.
  • Continuously expand knowledge and understanding of community resources and services Facilitate patient access to community resources, including locating housing, food, clothing, prenatal classes, parenting, and relevant mental health services. Assist patients in utilizing community services, including scheduling appointments with social services agencies and assisting with completion of applications for programs for which they may be eligible
  • Facilitate communication and coordinate services between providers and the patients/patients. Coordinate and monitor services, including comprehensive tracking of patients' compliance in relation to care plan objectives
  • Work collaboratively and effectively within a team. Establishes positive, supportive relationships with participants and provides feedback to other members of the team. Build and maintain positive working relationships with the patients, providers, care managers, medical residents, and office staff. Work to reduce cultural and socio-economic barriers between patients and institutions

 

Characteristics of an Ideal Candidate

  • Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community
  • Ability to plan, implement, and evaluate individual patient care plans
  • Knowledge of transportation and other barriers to care that may be encountered by patient
  • Ability to communicate medical information to health care professionals and care coordinators over the telephone
  • Basic computer skills
  • Skill in organizing resources and establishing priorities
  • Creative and analytical thinking
  • Bilingual highly desired

Knowledge Required for the Position

  • High school diploma or GED; at least 3 years of experience directly related to the duties and responsibilities specified. 
  • Completed degree(s) from an accredited institution preferred
  • Knowledge of community agencies and resources
  • Working knowledge of patient centered medical home model and multi-system outreach programs related to health care delivery, clinical education, and health-related services
  • Ability to plan, implement, and evaluate individual patient care plans
  • Knowledge of transportation and other barriers to care that may be encountered by patient
  • Ability to communicate medical information to health care professionals and care coordinators over the telephone

Language Proficiency Requirements

Bilingual, English/Spanish, a plus