Community Health Worker - Transitions of Care

Description

Join the Erie team! Motivated by the belief that healthcare is a human right, we provide high quality affordable care to support healthier people, families, and communities. Erie delivers holistic care to help every member of the family stay healthy and active from infancy through adulthood. Since 1957, we have provided high-quality care to diverse patients most in need, regardless of their insurance status, immigration status, or ability to pay.

Erie Family Health Centers, a top workplace in Chicago and suburbs, is looking for a valuable addition to our Patient Programs and Support Services! This role conducts risk assessments, schedules appointments, and links patients to needed resources and supportive services within and outside Erie. The CHW works closely with providers, other clinical care team members, and patient programs staff to identify and support patients.

An ideal candidate would enjoy working as part of a collaborative team to achieve high levels of productivity and maximize services. This position requires someone with both technical expertise and a deep commitment to providing compassionate care that honors the dignity and individuality of every patient.

At Erie, we are proud to provide competitive salaries, high-quality health care plans, generous time off benefits, retirement benefits, and more! Erie employees are eligible for Erie’s Full Benefits Package that includes Medical, Dental, Vision, Life and Disability Insurance and Flexible Spending (FSA) for Health Care or Childcare. Retirement Programs: 401(k) program with Erie matching $0.50 for every $1.00 up to the first 5% of the employee’s biweekly salary. Annual Paid Time Off: starting at 20 days of PTO, and 8 paid holidays. Competitive salary, annual merit increases, plus room for growth and career advancement.  

*Compensation is based on each candidate's experience, skills, and education within the range identified for the role. Candidates who meet the minimum requirements of role will start at entry in the range. Any additional skills, experience, and education will be reflected in the compensation offered.

Main Duties & Responsibilities

• Conducts transition of care outreach to patients or individuals supporting their care transitioning from hospitals and other care settings. Complete appropriate assessments and documentation for patients transitioning between the hospital, Emergency Department, Skilled Nursing Facilities, home, and other care settings.
• Collaborates with Erie’s Licensed Care Managers (LCMs) - Transitions of Care (TOC) to provide care coordination services to facilitate transition of care between hospital, consulting physicians, community resources, and Erie, including handling cases that require follow-up per external partner request.
• Documents care team communication, resulting action steps, and activities in Erie’s electronic health record (Epic) for all participating patients, aligned with Erie and CARES Act standards (e.g., no medical jargon, etc.).
• Works with patients in short- and long-term capacities to coordinate care.
• Provides resources to patients based on identified needs, or links patients to other teams that may be able to assist.
• Conducts chart reviews, utilizes electronic medical records, conducts brief assessments and motivational interviewing, and documents patient reported medication management.
• Monitors and responds as appropriate to outside patient care alerts, including but not limited to Care Everywhere, PointClickCare ADT, SASS alerts, and MH Connect notifications.
• Attend monthly team meetings, biweekly check-in, and quarterly all-staff meetings

Qualifications

Education

• High School Diploma or equivalent required

Skills and Knowledge

• Strong computer skills required: expert in Microsoft Office, Excel and ability to learn to expert level in other electronic databases (Epic electronic medical record system, etc.).
• Experience identifying, referring to, and working with community-based organizations preferred.
•  Experience with health system navigation and patient education preferred.
• Phone-based outreach experience preferred
• Attentive to detail required
• Strong interpersonal and oral communication skills required.
• Bilingual fluency (English/Spanish) preferred but not required. (May be required to assist or work with non-English/Spanish only speaking patients and/or guests.)
• Previous experience and/or interest working in a healthcare setting preferred

Preferred:

• Community Health Worker training
• Associates degree, some college or bachelor’s degree

The Erie Advantage Pledge

WORKING TOGETHER FOR WHAT MATTERS MOST

Erie makes a pledge that all current and future employees can feel confident that:

• Our mission, vision, and values unite us.
• Our voices matter.
• We do things well.
• Our inclusive culture promotes balance and belonging.
• We find our career sweet spot at Erie.

Salary : $18 - $22