Community Health Worker - Enhanced Care Management Care Coordinator

Description

Community Health Worker / Enhanced Care Management (ECM) Care Coordinator plays a critical role in reaching out to the community, providing education, and assisting individuals and families in accessing health insurance, healthcare services, and other needed supports. In addition to promoting health literacy and self-sufficiency, the ECM Care Coordinator is responsible for coordinating care for patients with complex medical, behavioral, and social needs, addressing barriers to care, and connecting patients to vital community resources.

A Community Health Worker (CHW) is a trusted member of and/or has a unique understanding of the community they serve. This relationship allows the CHW to act as a liaison between health and social services and the community, improving the quality, cultural competence, and accessibility of service delivery. Through outreach, care coordination, informal counseling, advocacy, and education, the CHW empowers individuals and builds community capacity to achieve better health outcomes. This role focuses on proactively engaging high-risk patients, addressing social determinants of health, and collaborating with interdisciplinary teams to deliver comprehensive, patient-centered care.

Essential Duties and Responsibilities include the following:

Care Coordination and Individualized Planning

• Coordinate care for patients with complex needs, ensuring access to a range of services and resources.
• Develop, implement, and monitor individualized care plans tailored to each patient's unique needs and goals.
• Collaborate with interdisciplinary teams, including primary care providers and behavioral health team members, to provide comprehensive care.
• Act as a liaison between patients, healthcare providers, and community services to bridge gaps in care.

Advocacy and Resource Connection

• Advocate for patients to access necessary services, such as housing, food assistance, transportation, and mental health resources.
• Assist patients in navigating the healthcare system, including follow-up care, specialty appointments, and referrals.
• Conduct outreach to locate and engage patients who are difficult to reach or at high risk for hospitalization.

Addressing Social Determinants of Health (SDOH)

• Assess and address social determinants of health that impact patients' well-being, including food insecurity, homelessness, or lack of access to transportation.
• Connect patients to appropriate community resources and social services to address non-medical needs.

Education and Support

• Offer guidance and support on self-care practices to improve patient outcomes.
• Provide social support by listening to patient and family concerns and helping develop problem-solving strategies.
• Support individualized goal setting using motivational interviewing and other patient-centered approaches.

Documentation and Compliance

• Maintain accurate and up-to-date records of patient interactions, care plans, and referrals.
• Ensure timely documentation in the electronic health record (EHR) and prepare reports for internal tracking and compliance with external reporting requirements.

Crisis Response and Quality Improvement

• Respond to urgent situations, such as potential hospitalizations, emergency department visits, or behavioral health crises, to coordinate care and improve outcomes.
• Participate in quality improvement initiatives to enhance care coordination processes and patient satisfaction.
• Monitor patient satisfaction and identify areas for improvement within the care management program.

Collaboration and Best Practices

• Participate in regular interdisciplinary care team meetings to discuss patient progress, barriers, and opportunities for improvement.
• Provide input on care coordination best practices and refine care pathways based on patient needs.
• Conduct individual and other community outreach and educational sessions to inform current patients, stakeholders and other community members in health care topics of interest including
• Other duties as assigned.

Requirements

Education and Experience:

Community Health Worker certification is required. High school dipl