007660 PRIMARY FUNCTION : The Community Health Worker (CHW) will assist individuals and communities to adopt healthy behaviors. The CHW will help patients and their families navigate and access community resources and services. The CHW will provide support to the selected practice care coordinators and providers through a team based care model. The CHW will provide social support, informal counseling, education on the various community resources and services, and advocate for individual and community health needs. The CHW will be a liaison between the patient/families and community service agencies. ESSENTIAL FUNCTIONS:
- Effectively communicates and navigates systems to include health care, social services, education and community resources to assure patients access and appropriate use of these services
- Identify problems and resources to help clients solve their problems with the goal of empowering the patient/family/others how to navigate
- Work in a community and hospital settings, or other designated settings, to ensure that the patients' needs are properly identified. This will include, but not limited to, home visitations, hospital visits, ED visits, other medical appointments and all other approved locations to work efficiently with the patient to provide stability
- Work with clinical social worker to ensure that all identified behavioral health needs are supported for the patient.
- Completes daily medical appointment reminders to assist with reduction in patients missing medical appointments
- Liaison between interdisciplinary team with medication refills, prior authorizations and other medical questions to avoid unnecessary hospital admissions.
- Complete assessments on patients to assist with identifying behavioral health and social determinants of health needs for the interdisciplinary team.
- Working with sickle cell transition population to ensure all patients need from pediatric to adult care have been accessed. This includes attending appointments, assisting with benefits, participating in annual retreats, meetings and grant projects related to transition.
- Works with the SCD community-based organization to provide support for patients/families and ensure partnership with institution.
- Work with interdisciplinary team on evaluation process to provide research documentation on the outcomes of the program.
- Developing an effective working relationship with the patient and caregiver through engagement, collaboration, advocacy, decision making and problem-solving activities
- Attend transition program events as needed
- Assist patient with navigating the systems of care.
- Attend all scheduled trainings, workshops and additional workshops as indicated by supervisor
- Identifies and help enroll eligible individuals in federal, state, and local private or nonprofit health and human services programs
- Serves as a liaison between patients/families/communities, healthcare agencies, and specialists.
- Provides Guidance and social assistance to patient's families and community residents
- Enhances patients' ability to effectively communicate with healthcare providers
- Provides culturally and linguistically appropriate health education materials within the scope of training
- Provides referral, follow-up services and schedule patient appointments as needed
- Assists patients and families in understanding and carrying out their healthcare providers' advice
- Follows-up whether patients are receiving and adjusting well to their care plans, providing additional resources as necessary.
- Compiles and tracks community resources available to and used by Jefferson's patient population
- Interacts with co-workers, visitors, and other staff consistent with the iSCORE values of Jefferson.
QualificationsEDUCATIONAL/TRAINING REQUIREMENTS: High School Diploma or GED
CERTIFICATES, LICENSES, AND REGISTRATION :Certified Community Health Worker training program preferred.
EXPERIENCE REQUIREMENTS :Prior experience in community outreach preferred.
Closing StatementAbout Jefferson Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University , home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health , nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years. Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.