ECM - Community Health Worker

Description

 Position Overview:

Under the guidance of the ECM Clinical Supervisor and reports to the ECM Lead Care Manager (LCM). The Community Health Worker (CHW is responsible for working effectively with the Enhanced Care Management (ECM) participants to improve their whole health through outreach and engagement activities, which are primarily field based. CHW works collaboratively as part of the ECM Care Team, members and their families, healthcare providers and works with the designated primary care provider (PCP) Care Team of our members. In coordination and management services in the Enhanced Care Management (ECM) program at Bayview Hunters Point Foundation for Community Improvement (BVHPF) and our Managed Care Plans (MCP). The Community Health Worker (CHW) services are preventive healthcare modalities, to lower the risk of diseases, and other health conditions to prolong life and to promote physical and mental health efficacy. CHWs are trusted members of their community who help address chronic conditions, preventive healthcare needs and health-related social needs, by ensuring ongoing delivery of high-quality supported care and guidance to ensure ECM Participants is receiving the best possible care by supporting the coordination of services for our clients, participants, members, and their families with complex medical, behavioral, and social needs. 

Requirements

Duties & Responsibilities:

Complex Case Management: Manage caseloads of complex cases by providing ongoing direct support, develop personalized Care Plans, conduct ACEs screening at every intake to identify needs for services and develop comprehensive assessments in collaboration with ECM Participants and their families, ensuring they are person-centered and aligned with member's needs, culturally and linguistically appropriate by setting goals and connections to community resources necessary to promote and address healthcare barriers and/or address health-related social needs. Documentation of care and progress in our electronic health record (EHR) systems. 

Individual Care Plan Oversight: Provide in an individual and or group settings to address issues that included but not limited to control and prevention of chronic conditions and or infectious diseases, mental health conditions and substance use disorders, perinatal health conditions, sexual and reproductive health, environmental and climate-sensitive health issues, child health and development, oral heal, aging, violence prevention. Address barriers to healthcare including providing information or instructions on health topics. The content of health education must be consistent with established or recognized health care standards. Health education may include coaching and goal setting to improve the ECM Participants health or ability to self-manage health conditions. Health navigation to provide information, training, referrals, and or support to assist ECM Participants and their families to access healthcare, understand the healthcare systems and or engage in understanding their health plan benefits under their assigned Managed Care Plan (MCP). Coordinate care with healthcare providers by providing regular communication with ECM Participants to ensure relevance and progress of their Care Plan and goals to adjust as needed. Participate in weekly case reviews and consult with ECM Care Team, PCPs before taking any clinical actions. 

 Resource Management: Assist ECM Participants and their families to participate in their medical and/or behavioral healthcare by overcoming barriers to care by following up in-person and by phone. Communicate and deliver easy to read information about health and wellness to the ECM Participations, families and in the community. Facilitate communication and collaboration among healthcare providers in identifying and coordinating resources, including healthcare, behavioral health, social services, and community support. In junction with other BVHPF program case managers for internal referrals. Accompany ECM Participants and families to appointments by driving, and or arranging transportation to and from appointments, hospital and skilled facilities. Staying up to date on the latest research and best practices in care coordination management and public health issues. 

 Crisis Intervention & Support: Provide guidance and support in situations requiring crisis management, ensuring that patients receive immediate and appropriate care and interventions by engaging ECM Participants and their families both in-person and on the phone, utilizing strength base, trauma informed and evidence-based approaches, such as Motivation Interviewing (MI) and promote collaboration between the ECM Participant, families and their ECM Care Team, Healthcare Providers to increase the members sense of control over their health. 

 Program Development: Models the highest ethical behavior in relationships with co-workers, supervisors, members, providers, and colleagues in the community while maintaining a positive holistic approach. Assist the ECM team and providers to understand the culture, norms, beliefs and preferences of the members and their community by representing the community’s voice. Helps create messages and materials that fit community culture and delivers messages to fit the culture of member. Promote a collaborative and effective working environment within the ECM program by engaging in strength, trauma informed, evidence-based communication strategies, such as MI, discussing responsibilities, sharing of tasks, resolving conflicts and participants case reviews. Engages in Continuous Quality Improvement (CQI) initiatives and projects, such as identifying and addressing gaps, and developing and testing new practices to improve the ECM program outcomes. Ensures documentation is accurate, helpful and compliant with regulatory requirements of BVHPF and MCPs. Contribute to the development and enhancement of ECM services, offering input on program improvements, workflow optimization, and best practices. Participate in ECM team meetings and perform other duties as assigned. 

Qualifications:

Experience: Minimum 3-5 years in outreach and engagement with combination with, high-need care coordination and management, including those with mental health conditions, homelessness, and substance use disorders, with at least 1-2 years lived experience, including experience working with LGBTQI , young people and their families, caregivers, child welfare, foster system, older adults and individuals with chronic illness communities. 

Licensure/Certification: CHW Certificate of Completion issued by State of California, or a State designee or a Violence Prevention Certificate. Possession of a valid California Driver’s License with a driving record that meets agency standards. Auto Insurance and access to a vehicle.  

Leadership Skills: Strong communication and interpersonal skills, with problem-solving skills. Ability to work independently and as part of a team. 

Knowledge: In-depth understanding of high-need care coordination, chronic disease management, behavioral health, social determinants of health (SDOH), community resources and healthcare services. 

Technical Skills: Proficiency in case management software such as: electronic health records (EHR), Avatar, Epic and data reporting tools, including knowledge of Microsoft Office, Internet browsers, etc. 

Physical & Additional Requirements:

Regular and reliable job attendance.

Effective verbal and written communication skills.

Exhibit respect and understanding of others to maintain professional relationships.

Independent judgement in evaluation options to make sound decisions.

Ability to work effectively in an open office environment surrounded by moderate noise and distractions.

Frequently required to sit; occasionally walk and stand; travel from the building to other sites.

Specific vision abilities required by this job include close vision, distance vision, depth perception, and the ability to adjust focus.

The employee must be able to meet case notes deadlines with time constraints. 

 Able to meet required state, federal, local and BVHP standards.

Live Scan fingerprinting and TB clearance as well as any other medical vaccinations may be required.

At least two COVID-19 vaccinations (preferred).

As part of our commitment to maintaining a secure environment, all candidates selected for this position will be subject to a comprehensive background check clearance. This clearance is a standard part of our employment process and is conducted in accordance with applicable laws and regulations.

Provide proof of California Driver’s Licenses, proof of insurance and current registration with a clean driving record. 

Additional Requirements: 

Bilingual (English/Spanish) skills preferred. 

Completion of a minimum of 6 (six) hours of continuing education training annually.

Top-Tier engagement in a variety of settings: in-person, phone, In-home, facilities.  

May require occasional evening and weekend to managed care   

Excellent verbal and written communication skills in writing and proofreading. 

Exhibit respect and understanding of others to maintain professional relationships. 

Ability to work as part of a team and independent judgement to make sound decisions.