Community Health Advocate

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Job DescriptionCompany: Oak Street HealthTitle: Community Health Advocate (RBE)Location: Remote / Field-Based - Multiple LocationsRole DescriptionCommunity Health Advocates (CHAs) work one-on-one with high-risk patients to get to know them as people and help them do the things that they think will improve their health such as offering a listening ear, connecting them to resources like food delivery, navigating the health system, or working out with them at the YMCA. This is an autonomous position which requires a consistent drive for excellence, ability to make appropriate and timely decisions, listen with empathy, and use effective problem-solving skills. CHAs are responsible for thorough and accurate documentation and working collaboratively within a multidisciplinary care team.Core Responsibilities

• Manage a caseload of patients and achieve established benchmarks for patient care
• Meet patients in their homes, at the hospitals or primary care clinic and conduct open-ended needs assessment to understand broadly what patients’ goals are for their health
• Use motivational interviewing to help patients create person-centered action plans for reaching their health goals.
• Use of critical thinking to create goals for patient success based on both clinical and patient identified goals
• Provide a wide variety of support (including emotional support, referral to community based resources, social services, clinical services, etc.) based on CHA discretion and available resources
• Make weekly contact (follow up calls and/or home visits) to patients
• Coordinate and communicate with clinical care teams to provide relevant information about patients goals, clinical emergencies, and patients concerns, and to obtain medical information needed to inform CHA work
• Co-facilitate a weekly support group for patients, where applicable 
• Work with other CHAs and staff to create a directory of community resources (e.g. food banks, housing assistance programs, childcare resources, etc.
• Attend interdisciplinary meetings with other medical professionals to align on readmission prevention planning
• Expertise in navigating Health Plan benefits and resourcing
• Accompaniment to specialist and provider visits
• Establishing and maintaining positive relationships with hospitals, PCPs, specialists and support staff to ensure seamless care coordination
• Patient advocacy and support while navigating Social Determinants of Health
• Efficient, quality and thorough documentation of patients enteractions including actions and goals of care to ensure effective communication among healthcare team members
• Navigate patient enrollment within transitional program and manage referrals from other team members
• Form relationships with and build an inventory of local community organizations 
• Other duties, as assigned

 What We are Looking ForDegree Requirements and Minimum Experience Required:

• High School Diploma required.
• Long-time resident of assigned location and good knowledge of the resources of these communities.
• Comfortable with home visits and outreach
• Prior experience as an outreach worker a plus

Skill Requirements:

• Ability to exercise good judgment with patients, clinical care teams, others involved in the delivery of interventions
• Ability to effectively manage time and tasks, prioritize, and stay organized
• Excellent oral and written communication skills
• Exceptional active listening skills
• Proficient in MS Word and computer data entry
• US work authorization
• Someone who embodies being Oaky

 What does being Oaky look like?

• Radiating positive energy
• Assuming good intentions