The Community Health Worker (CHW) does Care Coordination & Social Services. This position assists the clinical operations/care management teams. Under supervision of the care management supervisor, the CHW works with medical providers, primary care teams, and social agencies to provide short-term care coordination and connection to resources and support programs for patients to improve their health and well-being.

The CHW is responsible for the initial biopsychosocial assessment and performs telephonic, face-to-face, at the clinic or patient’s home. This is focused on the following areas: home visits, safety, support system, clinical or medical, identifying issues related to cognitive behavior changes, and informing the Supervisor. The CHW creates a plan to address patients’ social needs.

Essential Job Functions

The Community Health Worker (CHW):

• Provides services including facilitating the patient’s psychosocial adjustment along the continuum of care and transition to the next level of care.
• Develops effective relationships with the patient, family, and case managers. Engages the patient/family and collaborates, advocate, and problem-solves. Assist patients in their homes and community and communicate the program’s purpose.
• Educates on Advance Directives, helps complete forms, and provides information on POA
• Assists patients in care management with health-related social determinants and financial, emotional, and social issues. Helps patients identify socio-economic matters affecting their overall health and develop health/social management plans and goals.
• Provides community linkage for patients and families experiencing significant emotional, social, environmental, or financial stress to hospitalization, acute or chronic illness, and who need help meeting their continuing care needs
• Screens for Falls Prevention Program.
• Demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served with a thorough understanding of the principles of growth and development over the life span.
• Demonstrates awareness of the medical/ legal issues of patient rights and compliance with standards of regulatory and accrediting agencies.
• Documents all client encounters and contracts made on behalf of clients; completes and submits monthly reports. Documents activities, service plans, and outcomes effectively achieved by patients.
• Educates the client on the Emergency Room’s proper use and provides information for alternatives. Coach patients in the effective management of their chronic health conditions and self-care. Assists patients in understanding care plans and instructions. Motivates patients/clients to be active and engaged participants in their health and overall well-being.
• Provides support and advocacy during an initial home visit or when necessary to ensure patients' medical needs and referrals required are being conveyed. Follows up with both clients and providers regarding health/social services plans.
• Ensures patients and families have access to prescription, durable medical equipment (DME), and other services as identified
• Facilitates communication and coordinate services between providers and patients. Coordinates and monitors services, comprehensively tracking clients' compliance with care plan objectives.
• Travels to clinics or patient homes, community locations, agencies, and other outreach destinations. Performs miscellaneous job-related duties as assigned.

Minimum Required Education, Experience & Skills

Strong interpersonal and communication skills and the ability to work effectively with various constituencies in a diverse community.

• Knowledge of community agencies and resources.

• 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 client care plans.
• Knowledge of transportation and other barriers to caring for the client may encounter.
• Ability to communicate medical information to health care professionals and care coordinators over the telephone.
• Skill in personal computers and related software applications, including e-mail.
• Skill in organizing resources and establishing priorities.
• Creative and analytical thinking.
• Travel expected about 40% of the time.
• Car and valid driver’s license.

Preferred Education, Experience & Skills

• Associate degree in Business Administration or Human service, Paramedic or Certified Nursing Assistant, and successful completion of a Community Health Worker formal training program such as from a college or other educational institution is preferred.
• Medical terminology and background preferred.
• Can write and speak in English and Spanish.

Innovacare participates in E-Verify and will provide the federal government with your Form I-9 information to confirm that you are authorized to work in the U.S.