Community Health Worker

Job Summary

 

This role is a core member of the interdisciplinary care team (ICT), focused on building trust with members and supporting improved engagement in their medical and behavioral health care through promoting compliance with treatment plans.  This involves locating members who have been lost to care or unable to telephonically reach for scheduling hospital/ED follow up visits, providing peer support to members in the community setting and connecting members to community resources to meet social determinants of health (SDOH) needs. The CHW primarily interfaces with members in the community setting, including meeting members in their home or community location.

 

The CHW is knowledgeable of community resources and acts as a liaison between members and resources and helps members complete applications to necessary community-based and in-center services. This role establishes and maintains a trusting rapport with members, families, and relevant stakeholders for a specific assignment or for an estimated 3-6 month timeframe, as indicated, and based on the reason for referral.   

 

This role is key to member success in re-engaging in health care through building in-person relationships with members in their home setting, community locations, accompanying to specialist/PCP office visits and other individual community support. The CHW documents all interactions in the electronic health record, attends team meetings, and serves as a community-based liaison for communication between the member and multidisciplinary team.

 

Key performance indicators of this role include successful engagement with members, member adherence in care (e.g., attending PCP and behavioral health appointments), closing social determinants of health (SDOH) gaps, and overall reduction in member hospital utilization.

 

Duties and Responsibilities

 

• Manage an assigned caseload of members with the primary goal of engaging the member into care
• Prioritize outreach to members based on acuity level, difficulty reaching or engaging into care and reasons for referral based on an established list for CHW engagement.
• Outreach to members/caregivers/families in the community to locate, engage, establish trust, and assist in resolving barriers to care.
• Observe the home or community setting to identify needs related to social determinants of health, community integration, family/collateral information, etc., related to members’ health status.
• Document all information and interactions in the electronic health record.
• Develop culturally competent relationships with members
• Promote appropriate utilization of the health care system and AbsoluteCare services to reduce unnecessary ED or hospital admissions.
• Participate in the interdisciplinary care team (ICT) including case consultations, rounds, and follow up.
• Facilitate member enrollment in AbsoluteCare PCP, behavioral health and/or community care management programs
• Support community integration, independent living, and access to care.
• Responsible for prioritizing, independently scheduling visits and following up with members, including reviewing member information prior to outreach.
• Accompany members to medical, behavioral health, and/or community resource appointments to support adherence to treatment plan, advocate for member needs, and assist in completion of applications, as appropriate.
• Work with the member, member’s support system and community programs to establish sustainable SDOH and companion support; when applicable.

 

Minimum Qualifications

 

• High School degree or equivalency required.
• Active driver’s license, reliable personal vehicle, and proof of insurance in state of practice.
• 2+ years serving the needs of the local population, preferably in a healthcare setting or community/outreach organization with experience in the following:
• Working knowledge and relationships with community resources and support services
• Cultural competence in working with a diverse population
• Delivering peer support
• Ability to work independently in the field up to 80% of the time in members’ homes or in community locations.
• Strong communication skills to effectively communicate with members, community p