Community Health Worker - Population Health

The Community Health Worker (CHW) will be responsible for assisting patients to navigate and access community services and adopt healthy behaviors. The CHW supports the Primary Care and Population Health Providers and staff through an integrated approach to care management and community outreach to improve patient care and outcomes. The CHW will provide culturally and linguistically appropriate support, guidance and encouragement for the patients and their families/caregivers, as appropriate. The Community Health Worker assists patients to receive the needed follow-up care through their primary care provider/medical home. The CHWs spend time in the communities that they serve to ensure patient compliance and adherence with screenings, appointments, medication use and to be the bridge between the patients, community and the primary care practice.

Duties and Responsibilities:

• Conveys the purpose of the program to the patients and the impact that the service will have on their medical care and outcomes.
• Helps patients develop health management plans and goals through assessment tools to identify individual patient needs.
• Follows-up with health management plan and goals with both the patient and providers.
• Coaches patients in effective management of their chronic health conditions and self-care habits, such as preventing and managing uncontrolled diabetes.
• Assist patient in understanding plan of care, medications, self-management activities and instructions.
• Documents patient vital signs, activities, plan of care and results in the electronic medical record in an effective manner while strictly adhering to the policies and procedures in place.
• Works collaboratively and effectively within a team.
• Establishes positive, supportive relationships with participants and provide feedback.
• Helps patients in utilizing resources, including scheduling appointments, and assisting with completion of applications for programs for which they may be eligible for to improve health outcomes.
• Assists individuals with self-management of chronic health conditions and medication adherence
• Assists patients in accessing health related services and overcoming barriers to obtaining needed medical care, social determinants of health and services.
• Facilitates communication and coordinate services between providers.
• Motivates patients to be active, engaged participants in their health.
• Works effectively with people (staff, clients, providers, agencies, etc.) from diverse backgrounds in reducing cultural and socio-economic barriers for patients.
• Conducts intake assessments and educational and health maintenance sessions at the convenience of the patient in the patient home, office, through telephone or other designated area.
• Builds and maintains positive working relationships with the patients, providers, nurse case managers, agency representatives, supervisors and office staff.
• Continuously expands knowledge and understanding of community resources, services and programs provided in the community as well as within Tandem Health.
• Confers as needed and on a timely basis with health center providers regarding patient issues and concerns.
• Collects, reports, and enter data for purposes of evaluating CHW activities and completing grant reporting.
• Identifies patients at risk for poor adherence.
• Communicates with patients after a hospital discharge to follow up on treatment plans.
• Helps patients connect with transportation resources.
• Acts as a patient advocate and liaison.
• Attends regular staff meeting, trainings and other meetings as requested.
• Manages assigned caseload of patients.
• Other duties as assigned.

Qualifications:

• Education and Experience:
• High School Diploma or its equivalent required.
• Experience working as a medical assistant in a primary care setting preferred.
• Experience working in a community-based setting for at least 1-2 years preferred.
• Must be willing to seek Certification for Community Health Worker in accordance with the South Carolina state-approved certification process.
• Current South Carolina driver's license required. Driving record must meet Tandem Health insurance standards upon employment, and continually thereafter.