About this role
Role Overview
- Conducts in-home, clinic-based, telephonic, and community-based wellness visits with patients/members as assigned.
- Completes health risk assessments, social needs screenings, and follow-up activities to identify barriers related to health care access, food, housing, transportation, medication access, safety, utilities, and other social drivers of health.
- Provides support, education, and reinforcement to help patients/members understand and follow their individualized care plans.
- Supports medication adherence by providing reminders, identifying barriers to medication access or understanding, and escalating concerns to the appropriate clinical team member.
- Assists patients/members with appointment reminders, follow-up care needs, preventive screenings, immunizations, routine checkups, and appropriate use of their medical home.
- Facilitates transitions of care after hospital, emergency department, or skilled nursing facility discharge by assisting with outreach, follow-up needs, appointment coordination, resource connection, and escalation of concerns.
- Connects patients/members to appropriate internal and external resources.
- Helps patients/members access community-based resources, including food assistance, housing support, transportation resources, utility assistance, financial assistance programs, and other social service supports.
- Assists patients/members with completion of forms, applications, resource referrals, and follow-up steps needed to access programs or benefits for which they may be eligible.
- Serves as a trusted liaison between patients/members, families, community organizations, health care providers, clinics, and social service agencies.
- Builds positive, supportive relationships with patients/members while promoting engagement, self-management, and active participation in health and wellness goals.
- Documents all encounters, outreach attempts, assessments, identified needs, interventions, referrals, and follow-up activities in the appropriate electronic system according to departmental expectations.
- Escalates concerns related to safety, unmet social needs, changes in health status, behavioral health concerns, medication concerns, suspected abuse/neglect, or barriers requiring clinical or social work intervention to the appropriate team member.
- Maintains current knowledge of community resources, health care services, payer resources, internal programs, and referral pathways.
- Works collaboratively and effectively within a team while also demonstrating the ability to work independently in community-based settings.
Requirements
- High School diploma or equivalent
- Valid Driver’s License
- Completion of a Community Health Worker, Community Healthcare Worker, Community Health Education Resource Person, or similar curriculum within one year of hire.
- CPR certification.
- Medical Assistant, Certified Nursing Assistant, Patient Care Technician, Health Coach, Peer Support, or other health care/community health-related certification.
- Prior experience in a health care, community health, public health, social service, case management, care coordination, patient navigation, or related setting.
- Experience working directly with patients, members, families, or community members to address barriers to care.
- Experience with electronic health records or other documentation systems.
- Experience supporting patients with chronic conditions, preventive care needs, medication adherence, transitions of care, or social drivers of health.
- Experience conducting outreach, home visits, community-based visits, or field-based work.
Benefits
- Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Frequent standing, sitting and walking or ability to sit for long period of times.
- Ability to walk moderate distance indoors and outdoors
- Ability to lift, push, or pull a minimum of 40 pounds
- Visual acuity(corrected)-keen for both distance and near objects; Hearing (aid permitted) –must be able to function without use of lip reading.