Integrated Care Team - Community Health Worker

• Transitions of Care
• Follow up on patient referrals generated by the central population health TOC team to ensure post- discharge, risk mitigation strategies, including, but not limited, to posy-discharge follow-up appointments and resumption of home-based services.
• Escalate to the primary care team any barriers that affect the potential for re-admission or preventable ED utilization.
• Providers transitions of care updates to the integrated care team, including participation in pre-visit planning activities
• Engages (outreaches) with patients between visits either by phone, home, or community visits.
• Supports efforts to meet identified key performance indicators and quality metrics; participates in quality improvement efforts
• Uses strategies such as motivational interviewing, harm reduction, and strengths-based approaches to support members in attaining stated goals
• to improve skills and role-specific certifications or specialization
• Educates patients how to utilize mobile devices or computers for telehealth appointments.
• Ensures appropriate documentation of visits and activities with EHR; documents visit, phone calls and any contact.
• Performs chart reviews.
• Participates in ICT meetings.
• Complies with all applicable organizational and departmental policies.
• Other duties as assigned.

Qualifications

• and Experience:
• Community Health Worker Certification required including a commitment or willing to obtain certification within 6 months of hire.
• CPR Certified.
• Bilingual English/Spanish speaking preferred.
• Working Knowledge of community resources and ability to assess and implement based on assessment.
• Effective problem solving and critical thinking skills including need for escalation.
• Demonstrated success in working as part of a multi-disciplinary team.
• Experience working with patients with chronic medical and behavioral health needs.
• Demonstrated experience working with diverse patient populations and workforce.
• Must be flexible and adaptable to change.
• Strong organizational skills with ability to prioritize, multi-task and independently manage work demands, including escalation to supervisor when needed.
• Demonstrate the ability to work independently, while collaborating as needed with others if needed.
• Must demonstrate excellent interpersonal communication and written skills.
• Additional desirable qualities include enthusiasm and passion for helping patients in a non-judgmental and empathetic nature.
• Must demonstrate the basics of cultural competence when dealing with a diverse population.
• Must have a valid driver's license and access to reliable transportation.
• Must demonstrate a working knowledge of Microsoft Office: Word, Excel, and PowerPoint.
• Must be willing to learn and utilize telehealth technologies (video, chat), for a variety of services.
• Willing and able to travel to patients’ homes, and in the community as needed, based on patient’s needs.

#GLFHC offers a great working environment, comprehensive benefit package, growth opportunities and tuition reimbursement.