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As a Community Healthcare Worker Specialist, CHWS you will support the healthcare team by providing patient coaching and conducting motivational interviewing to support patients, families, and caregivers in achieving self-management, self-efficiency, and behavior changes to improve patient health and care outcomes. You will also assist in referring our patients to various community resources. The Community Healthcare Worker Specialist will require CCHW and CCP certification and demonstrate the skills necessary for this position. The Community Healthcare Worker Specialist completes the PRAPARE tool for patients to identify social determinants of health. The CHWS works independently and meets with the Coordinator of CHW’s. This position will report to the Assistant Site Operations Director.
Job Responsibilities
- Establishes trusting relationships with patients and their families while providing general support and encouragement.
- Complete follow up visits with patients in the community and in the home.
- Coordinate resources for identified problems including community mental health services, homelessness, substance abuse and food insecurity.
- Provides ongoing follow up, basic motivational interviewing and goal setting with patients/families.
- Serves as a liaison between clinical staff and patient, by following up with patients regarding their appointments, referrals, and needed resources.
- Help patients fill out applications for medical assistance and SNAP (Supplemental Nutrition Assistance Program).
- Helps patients set personal goals and attend appointments.
- Provides referral for services to community agencies as appropriate.
- Helps patients connect with transportation resources and gives appointment reminders to aid in compliance with prescribed plan of care.
- Helps patients connect to needed resources to carry out plan of care (MOWs, HH, Prescription assistance, etc.)
- Works closely with integrated medical team to ensure that patients have comprehensive and coordinated care.
- Remains knowledgeable about community resources appropriate to needs of patient/family.
- Continuously validates and evaluates the effectiveness of the community resources.
- Provides consistent communication to Medical Provider/Care Team Nurse to evaluate patient/family status and reports progress and compliance with identified plan of care.
- Enables and improves culturally and linguistically competent services and care by making efforts to understand the community culture and resources.
- Conducts outreach, implements programs in community that promotes, maintains and improves community health needs and provides resources.
- Collects data to help identify community health needs.
- Advises community groups on chronic disease and diabetes self- management, hypertension, and nutrition.
- Advises clients on general health and exercise and self- care activities.
- Identifies age appropriate needs and resources.
- Follows up hospitalizations and no shows.
- Provides situation appropriate social support to the patient utilizing experience lived and learned through training provided at HealthLinc.
- Attend initial and continuing education training programs including self-directed reading and in-person and online learning.
- Provides informal counseling as needed.
- All HealthLinc staff is committed to engage in quality improvement initiatives that align with and support Patient-Centered Medical Home (PCMH).
- Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.
Required Qualifications
Education/Training
- High school diploma or equivalent
- Successful completion of a formal CHW training program and Chronic Care Professional (CCP) certificate (Must complete within 6 months of hire date. HealthLinc will provide training upon hiring).
- Certified Medical Interpreter-Spanish (not required but highly preferred)
Experience
- At least 1-2 years of experience as patient/community facing role within a nonprofit environment, food pantry, WIC, etc. preferred.
Skills/Job Requirement
- Strong organizational and time management skills
- Proven ability to work well in a team environment
- Ability to remain flexible and adaptable
- Knowledge of some medical terminology
- Excellent written and verbal communication skills
- Transportation and valid driver’s license
- Ability to follow HealthLinc policies and procedures
Technology Skills
- Operate a multi-line phone system and other office equipment including printers, fax machines, etc.
- Basic computer skills (Microsoft Office, EHR, online sources, etc.)
