Community Health Worker Certified-2

Location:

Work from home (Pennsylvania)

Shift:

Days (United States of America)

Scheduled Weekly Hours:

40

Worker Type:

Regular

Exemption Status:

No

Job Summary:

The Certified Community Health Worker (CCHW) within the Social Needs Resource Hub (SNRH) provides patient-centered outreach, primarily through telephonic engagement, to individuals with identified social needs. Working within a team-based model, the CCHW collaborates with healthcare teams, community-based organizations (CBOs), and hub colleagues to assess needs and coordinate appropriate support.
The CCHW utilizes motivational interviewing and problem-solving techniques to educate patients and connect them to community resources that address social determinants of health, including transportation, food insecurity, housing, financial strain, and utilities.
This role includes facilitating referrals and partnering with CBOs through the Neighborly platform to ensure timely and effective linkage to services. The CCHW conducts follow-up outreach to confirm successful connections and address barriers, supporting a shared team workflow and accountability model.
Accurate and timely documentation within Geisinger’s electronic medical record (EMR) is required to capture outreach efforts, referrals, and outcomes, supporting reporting, quality improvement, and program evaluation

Job Duties:

• Orients and assesses new Community Health Workers.
• Provides regular assessment of the level of proficiency demonstrated by staff during the orientation period in order to support decisions to move staff along in training or refocus until proficiency is met.
• Assists in the identification and outreach of medically complex patients.
• Collaborates with the multidisciplinary team in the development and implementation of the care plan.
• Engages patients by way of phone call, home visit, hospital visit, and accompanying patients to Providers appointments as needed.
• Completes vital signs.
• Identifies gaps in care and connects members with resources.
• Facilitates telemedicine visits with members and providers.
• Performs disease specific education.
• Conducts Medication Review to ensure medication adherence.
• Conducts safety evaluations in patients home.
• Facilitates adherence to treatment