NON-CERTIFIED COMMUNITY HEALTH WORKER-AMBULATORY CARE MANAGEMENT
: Job Details :

Job DescriptionJob Overview:Functions as an integral part of the Ambulatory Care Management team to support patients with high risk of readmission and/or those with clinically complex chronic conditions. Under the supervision of a nurse or social worker, the Ambulatory Care Management-Community Health Worker provides care coordination and advocacy to patients, including outreach and engagement, linkage of the patient with resources (food, housing, transport, financial, community based services) as well as linking the patient with care. This position provides input into the client's situation and action plan. Assists patients/families, staff and systems to achieve high quality, evidence-based, cost-effective, and patient-focused outcomes. Providing support services to the PHO and all of its value-based contract members including but not limited to care coordination, home health visits, and counseling.Job Requirements:High School DegreeBasic Life Support for Healthcare Providers (BLS)Knowledge of priority neighborhoods Strong oral communication skills and interest in the health of patients and familesJob Responsibilities:Collaborates with the care team and serves as a resource to coordinate access to local community agencies and assists families and patients in accessing appropriate services to meet identified needs. Coordinates referrals for services and facilitates contact to community-based organizations on client's behalf, to achieve positive health outcomes. Interacts with clinical and medical personnel across all hospital inpatient and outpatient service lines to ensure collaboration across care settings and meaningful integration at transition points.Contributes to assessments, gathering information from the patient, family, and caregivers regarding the following: patient's level of functioning, environment, appropriateness and adequacy of support system related to illness and ability to cope. Reports information back to the multidisciplinary care team, and document interventions in patient record. Monitors patient's adherence to health improvement or treatment plan. Intervenes with patients and patient's representatives regarding emotional, behavioral, and financial barriers to current illness and/or disability . Conducts patient visits, provider visits and community based visits as needed to ensure effective support and achievement of patient's goals.Coaches and motivates patients as directed, utilizing behavioral interviewing techniques to identify and address barriers to to effective patient self-management of chronic conditions (i.e. education level, language barriers, etc.) and adherence to treatment recommendations. Participates in quality improvement initiatives; activities may include data collection, chart review, interdisciplinary collaboration, analysis of patient data and inter-professional staff meetings.Other Job-Related Information:Working Conditions:Climbing - OccasionallyConcentrating - FrequentlyContinuous Learning - FrequentlyHearing: Conversation - ConsistentlyHearing: Other Sounds - FrequentlyInterpersonal Communication - ConsistentlyKneeling - OccasionallyLifting