Community Health Worker - Must live in Oklahoma

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Position Summary

Qualified candidates preferably will reside within the region which includes the following counties: Creek, Okfuskee, Seminole, Pontotoc, Okmulgee, Hughes, Coal, Atoka, Bryan, Wagoner, Muskogee, McIntosh, Pittsburg, Atoka, Bryan, Choctaw, Pushmataha, Latimer, Haskell, Cherokee, Adair, Sequoyah, Le Flore, Pushmataha and McCurtain.

Community Health Workers serve the local community as a bridge between the member and family and the healthcare/social services system through member contact, face-to-face coaching sessions, outreach and education. By providing these services, Community Health Workers help Aetna Better Health members attain and maintain better health outcomes, have access to and fully utilize needed social supports, improve relationships with health care practitioners/providers, and help all parties learn about each other’s culture. The Community Health Worker role is meant to assist with access to services and to improve the quality and cultural competence of service delivery.

Fundamental Components:

• Engage members who are experiencing, or are at risk of, health disparities, to improve their engagement, access to care, and their overall health.
• Conduct home visits with members to reinforce following the care plan, adjusting tasks to fit with the member’s culture, language, and religion, improve access to care, and identify health care and social needs.
• Obtain and educate members about available SoonerSelect Program services.
• Educate healthcare professionals and providers about protective health factors and the social determinants of health that may be impacting member’s health and treatment plan through various communication channels.
• Advocate on behalf of the member and their preferences with respect to receiving member and family-centered care.
• Build and maintain positive working relationships with the members, their circle of support, providers, care coordinators, and other health plan support staff.  
• When applicable, serve as a member of the Interdisciplinary Care Team (ICT) and the  multidisciplinary case rounds supporting the member to bridge information between the member and the care team regarding any identified cultural and/or psychosocial elements.
• Work to reduce cultural and socio-economic barriers between members and institutions.
• Assist with care plan implementation and member education during in-home visits, help develop care management strategies, and work with team members to provide linkages that address the various health and social needs of members.
• Assist members to identify socio-economic issues that affect their overall health and develop  health/social management plans and goals.
• Identify gaps and opportunities to strengthen systems of care within the member’s community and assist members in utilizing community services, including scheduling appointments with social services agencies, (including transportation vendors) and assisting with completion of applications for eligible programs.
• Assist members to access community-based resources to address non-medical needs and to support the member’s Care Plan objectives and independence.
• Support medication adherence by reviewing the member’s current medication list and assist in obtaining refills.
• Accompany members to appointments as needed or requested.
• Provide support to member with filing grievances and appeals.
• Outreach, engage, and support members for re-enrollment and primary care provider (PCP) or provider assignment.
• Enter and maintain member records in electronic health record system, compile reports and complete other program documentation in a timely manner.
• Travel extensively to client homes, community locations, various agencies, and other outreach destinations.
• Ability to effectively provide support care to socially and medically complex patients in a variety of non-traditional settings.
• Exceptional organizational and interpersonal skills, with attention to detail required.
• Ability to work collaboratively in a team and manage multiple priorities, utilizes effective time m