Community Health Worker

We are searching for a Community Health Worker to join the team! As a Community Health Worker, you will work closely with the physician organization, medical providers, primary care teams, and social services agencies to provide short-term care coordination related to Social Determinants of Health (SDOH) needs. Coordination to include linkage to community resources and support programs, assisting patients to improve their health and general well-being through education and provision of appropriate services.

Primary Duties:

• Conducts outreach to targeted patient population to identify community resource needs.
• Conducts SDOH screenings on patients.
• Assists patients in identifying socio-economic issues that affect their overall health and in developing self-management plans and goals.
• Documents all patient encounters; completes and submits monthly reports; maintains comprehensive electronic patient files. Documents activities, treatment plans, and outcomes achieved by patients in an effective manner.
• Facilitates communication and coordinates services between providers and the patients, and tracks patient compliance with the care plan objectives.
• Provide appropriate billing code for services provided.
• Creates and maintains a comprehensive community resource database relevant to clinics’ patient populations.
• Participates in care team meetings and contributes to the patient plan of care.

Minimum Qualifications:

• High school diploma or GED
• CHW certification or willingness to obtain upon hire
• 1 year experience relevant to position and responsibilities
• Strong interpersonal and community skills and ability to work effectively with a diverse community
• Knowledge of community resources and agencies, for example- knowledge of transportation and other barriers to care
• Working knowledge of multi-system outreach programs related to health care delivery, clinical education, and health-related services
• Ability to plan, implement, and evaluate individual patient care plans
• Ability to communicate medical information to patients over the phone
• Skill in use of personal computer and related software applications, including email and excel
• Creative and analytical thinking

Preferred Key Skills and Abilities:

• Knowledge of the PCMH and PCMH-Neighbor (PCMH-N) models of care
• Experience with EHRs, disease registries, or other medical software
• Billing and coding experience 

Who We Are:Aledade, a public benefit corporation, exists to empower the most transformational part of our health care landscape - independent primary care. We were founded in 2014, and since then, we've become the largest network of independent primary care in the country - helping practices, health centers and clinics deliver better care to their patients and thrive in value-based care. Additionally, by creating value-based contracts across a wide variety of payers, we aim to flip the script on the traditional fee-for-service model. Our work strengthens continuity of care, aligns incentives, and ensures primary care physicians are paid for what they do best - keeping patients healthy. If you want to help create a health care system that is good for patients, good for practices and good for society - and if you're eager to join a collaborative, inclusive and remote-first culture - you've come to the right place.
What Does This Mean for You?At Aledade, you will be part of a creative culture that is driven by a passion for tackling complex issues with respect, open-mindedness and a desire to learn. You will collaborate with team members who bring a wide range of experiences, interests, backgrounds, beliefs and achievements to their work - and who are all united by a shared passion for public health and a commitment to the Aledade mission.
In addition to time off to support work-life balance and enjoyment, we offer the following comprehensive benefits package designed for the overall well-being of our team members:Flexible work schedules and the ability to work remotely are available for many rolesHealth, dental and vision insurance paid up to 80% for employees, dependents, and domestic partners Robust time off plan 21 days of PTO in your first year 2 Paid Volunteer Days & 11 paid holidays12 weeks paid Parental Leave for all new parents6 weeks paid sabbatical after 6 years of serviceEducational Assistant Program & Clinical Employee Reimbursement Program401(K) with up to 4% matchStock optionsAnd much more!
At Aledade, we don’t just accept differences, we celebrate them!   We strive to attract, develop, and retain highly qualified individuals representing the diverse com