Community Health Worker

Job Description

This is a fully remote role.

A bit more this role: 

Devoted Medical was founded on the belief that if we treat each patient like we would our loved ones, we can meaningfully improve healthcare experiences and outcomes for some of America’s most vulnerable patient populations. The Gold Care Program is at the heart of this goal: we are a highly collaborative, multidisciplinary team of physicians, nurse practitioners,  nurse case managers, social work case managers, community health workers, and outreach specialists united by our mission to build a better care delivery system for Devoted’s most complex members.  Through a mixture of in-home and virtual interventions, we provide whole-person clinical, social and logistical support for patients with complex chronic conditions and patients at high risk of hospital admissions.

The Community Health Worker (CHW) is vital to the Gold Care Program, playing a critical role in building trusting patient relationships and empowering patients to live healthy, dignified, independent lives. The CHW’s primary responsibilities include in-home and/or virtual patient visits (dependent on geography and program needs) using the 5M’s framework, front-line patient advocacy, community resource connection, care navigation/coordination, and wellness & life skills coaching (details below).  To succeed in this role, an individual must be an adaptable & resourceful problem-solver, a compassionate & collaborative team player, and feels a deep connection to our mission to treat each of our patients as we would our own family.

Your Responsibilities and Impact will include:

Patient Advocate & Community Resource Connector

• Screening patients for Social Determinants of Health (SDOH) needs & mobilize appropriate community-based resources, ensuring long term patient success

• Identify & maintain list of community resources to meet patient needs (i.e., transportation, housing, financial, food, medication discounts, support groups)

• Perform a mixture of virtual, telephonic & field-based (depending on geography) patient outreach, education & engagement visits to build rapport and overcome barriers

Care Navigator/Coordinator

• Serve as Care Traffic Controller, working closely with patients’ PCP, specialists, and the interdisciplinary care team to facilitate and track resolution of clinical orders, such as scheduling appointments, diagnostic testing, DME, and Home Health

• Collaborate with interdisciplinary care team in reviewing patient panel needs and expediting/prioritizing key tasks such as scheduling follow-up visits and coordination of STARs gaps closure

• Prepare for, and actively participate in, weekly interdisciplinary care team meetings, helping the team to identify high risk patients, solutions to overcome barriers, and defining next steps towards meeting goals

Wellness & Life Skills Coach

• Assist patients with practical skill development, such as tech and health literacy, smoking cessation, budgeting, and nutrition education

• Conduct Fall Risk Assessments in home and provide education to patient on safety concerns identified

• Educate & motivate patients’ families and caregivers on patient needs to establish a sustainable support system

Required skills and experience:

• Community Health Worker Certification, Certification of Medical Assistant (CMA), Registered Medical Assistant (RMA), or an Associates degree or higher in health sciences or related field and 3+ years’ work experience in a healthcare setting 

• Understanding of how to identify community resources and experience working with patients to access these

• Experience working on an interdisciplinary team of healthcare professionals

• Comfortable working with internal and external stakeholders to advocate for our patients

• Prior experience working with complex patients and/or underserved populations

Desired skills and experience: 

• Bilingual preferred (English/Spanish) but not required

• Geriatric experience or experience caring for a Medicare population

• Health insurance experience, particularly Medicare Advantage

• Two (2) years of experience in outpatient medical care, with a bonus if you have experience with telehealth or house call visits

Attributes to success: 

• You love helping others improve their health and navigate a complex healthcare system with compassion, empathy, and warmth

• You are ab