Community Health Worker (Full-time Remote, Charlotte, North Carolina Based)

The Community Health Worker uses engagement strategies and strong community connections to assess and assist members to identify and seek resources that support their unmet health needs, while providing education on, and connection to their benefits. Connecting with members in the community is an essential requirement for building relationships and trust with members. Additionally, this position functions as a consultant within the Care Team to address barriers related to unmet health needs.

This position will require travel within the communities Alliance serves as needed. The selected candidate must reside in Charlotte, NC.

Responsibilities & Duties

Assessment

• Complete SDOH assessments (and reassessments), such as, not limited to, Care Needs Screening and Healthy Opportunities 
• Review completed SDOH assessments and/or update activities to address SDOH needs that emerge when completing plan of care (POC) activities
• Assist members with engaging additional services/community resources such as the Community Inclusion Planning Meeting (CIPM) prior to closing a POC
• As applicable, assess member awareness of and connection with Competitive Integrated Employment, or like supported employment services and programs 

Member Engagement & Education

• Meet members where they are; emotionally, socially, intellectually, and physically 
• Provide face to face and field/community-based support to each member (metrics for minimum required in-person engagement)
• Support members to complete processes to access resources and supports, as applicable
• Support members in understanding how to utilize resources and supports provided, as applicable
• Support SDOH barriers to accessing care
• Support health promotion, as applicable
• Partner with the member and care team to identify goals and member centered plan
• As applicable, educate members on engage them into care coordination or care management supports

Facilitate and Ensure Connection to Resources that Meet Member Needs

• Identify, problem solve, and work to overcome support needs for members regarding social determinants of health
• Submit referrals, and track outcomes, in NCCARE360 Platform to connect members to community service providers
• Support member with completion of applications for, to include, but not limited to, housing, food, transportation vouchers, childcare assistance programs in the communities where the member lives and works, and monitors successful linkage to resources
• Support member to become an engaged and active member in their community (eg. community organizational membership, relationships with neighbors, building of non-paid social network)
• Review eligibility and linkage to all internal programs including but not limited to flex funds, independent living initiative (ILI), other housing programs, the CIPM, and facilitate community inclusion planning with Community Health and Well-Being Department
• As applicable, refer member for assessment of eligibility for Competitive Integrated Employment, or like supported employment services and programs, and connect member to services and programs, as applicable

Collaboration

• Attend meetings related to care planning and resolving SDOH needs
• Collaborate with primary Care Manager regarding new needs identified in the referral process and discuss incorporation into plan of care
• Work within the organization to leverage programs and interventions to maximize member experience and to build social capital in member’s community of choice
• Develop in depth knowledge of various community systems and provide consultation and technical assistance to MCO clinical departments regarding available resources
• Collaborate with providers and providers of care management services to Alliance members
• Represent Alliance in System of Care activities to ensure an integrated System of Care approach for child and adult service systems
• Support Community Engagement team at Alliance, for community capacity network building and resource development

Provide Benefits Consultation to Members

• Ensure members know what benefits they are eligible to receive
• Assist members to enroll in benefit plans
• Communicate with Medicaid and Medicare benefit program Case Managers to resolve issues
• Assist with Medicaid enrollment and work with DSS to address enrollment issues
• Notify DSS of benefit issues and develop action plan to resolve

Documentation

• Maintain medical record compliance/quality
• Ensure timely documentation of Care Coordination activities as required by department policy and procedures
• Document in the CM Platform System