Description

Esperanza Health Centers offers benefits to all its full-time employees:

BCBS Medical PPO Plans| Ameritas Dental |Eye Med Vision |Tuition Reimbursement up to $5,000 per year|10 Paid Holidays and 16 Days of Paid Time Off

Compensation (Based on experience and qualifications): $19.00-$23.00

The Wellness West is an initiative on Chicago’s west side that uses a comprehensive network of community-based partners and medical providers to screen community members with chronic illness for social determinants of health and provide a suite of comprehensive services to resolve identified issues. Based in the primary care practice, the Wellness West Community Health Worker (CHW) will work with patients to improve self-management of diabetes, hypertension and mild/moderate depression through assessment, enhanced self-awareness, education, self-monitoring and eliminating barriers to self-care by screening and addressing social drivers of health. 

In addition, the CHW will serve as a bridge between the patient, the medical system, and community-based organizations by building trusting relationships with community members served by the program. The CHW will also help in identifying barriers to accessing quality care, work with individuals to overcome these barriers, provide relevant referrals, follow-up with clients accordingly, and conduct hospital/home visits on a case-by-case basis.

Primary Duties and Responsibilities:

• Complete Health Risk Assessments (HRA) with patients living in target zip code.
• Assist with community resources and scheduling appointments.
• Enroll eligible patients in disease management program(s) and provide disease specific and preventive care patient education according to program requirements. 
• Manage a caseload of 80-100 patients
• Monitor patients (in person or by telephone) at required frequencies and track clinical outcomes such as PHQ-9, blood pressure, HbA1c. Use a worklist to identify and re-engage patients who are not participating as expected in the disease management program. 
• Support the treatment plan prescribed by PCPs, focusing on treatment adherence, side effects, other complications, and effectiveness of treatment. 
• Facilitate treatment plan changes for patients who are not improving as expected in consultation with the PCP. These may include changes in medications, treatments, or appropriate referrals for clinically indicated services outside the primary care clinic (e.g., social services such as housing assistance, vocational rehabilitation, subspeciality, mental health specialty care, substance abuse treatment, etc.).
• Prepare for and participate in regularly scheduled caseload oversight with the behavioral health specialist and/or an oversight nurse. 
• Communicate resulting treatment recommendations to the patient’s PCP (including review of e-consult recommendations if applicable). 
• Engage relevant care management staff with patient updates and ensure the care plan is consistently updated and integrated with disease management information. 
• Proactively outreach to patients to encourage them to become actively engaged in their own health through calm, compassionate communication and by utilizing techniques such as motivational interviewing and behavioral activation.
• Accurately document patient information, assessments, interventions and encounters
• Attends ongoing training and learning related to job position and duties.
• To live up to Esperanza’s mission of being truly involved in the community all staff members are expected to participate in program outreach activities; including but not limited to the Annual Fundraiser, Community Garden(s), and Health Fairs.

Esperanza Health Centers is an Equal Opportunity Employer (EOE) according to Title 44, Ill. Administrative Code, and Subpart C Section 750.150.

Requirements

• High school diploma or equivalent years’ experience.
• 0-3 years in community health, care coordination and/or related field
• Written and oral fluency in Spanish and English required.
• A close understanding of the community being served and knowledge about community resources appropriate to needs of patients/families.
• Good communication skills, such as active listening, sincerity, and tact.
• Ability and willingness to provide emotional support, encouragement and motivation to patients and families.
• Flexible disposition and growth mindset. 
• Proficient with Microsoft Office Suite or related software.
• Complete all required trainings and background checks. 
• Flexibility to work evenings and/or weekends, if necessary. Must be able to work on-site as needed. Current hybrid schedule.