Community Health Worker (CHW Transitions of Care Patient Experience)

Overview

The Community Health Worker (CHW) is a trusted member of the community, with an understanding of the culture, language, socio-economic status, and life experiences of the community served.

The CHW acts as a liaison and provides cultural mediation between healthcare, social services, and the community. The CHW helps Central Health members and patients access needed services and resources, as well as, building individual, community, and system capacity through health knowledge and self-sufficiency.

The CHW may provide a variety of services including social support, clinical education, advocacy, assistance with applying for health care coverage and resources.

The CHW will be responsible for patient documentation, project organization, and team collaboration. The CHW provides services through informing, outreach, patient navigation, and community health education.

The CHW may provide services through community outreach, the Central Health Navigation Center, Central Health Clinics, or other health care settings.

• Reviews, completes, and submits enrollment documents for patients admitted to Central Health contracted post acute skilled nursing facilities (SNFs) under the SNF Direct Care program.
• Organizes and facilitates focus groups at Central Health contracted SNFs and respite facilities with patients to capture and evaluate patient experience.
• Completes and submits patient experience surveys for Transitions of Care Post Acute programs.
• Provides feedback to Transitions of Care department on patient experience feedback obtained form surveys and focus groups.
• Provides feedback to High Risk Populations department on patient experience feedback obtained from surveys and focus groups.

Responsibilities

• Act as a member / patient advocate and liaison between the member / family, provider, health plan, Central Health, and community service agencies.
• Provides culturally appropriate educational information within scope of practice and effectively communicates to patients in a standardized manner with consideration to literacy, health literacy, resource management, software

utilization and navigation, and technological ability.

• Coaches participants to advocate and manage their health and social resources.
• Manages assigned caseload, documents activities, plans of care (when applicable), and reports results in an effective manner in accordance with organizational standards.
• Provides ongoing follow-up, basic motivational interviewing, and goal setting with members / families.
• Provides the patient / member perspective to inform messaging, activities, and effective ways to outreach and navigate the healthcare system.
• Helps members in utilizing resources, assisting with completion of applications for programs for which they may be eligible and / or including scheduling appointments, transportation, and supporting patient success.
• Assists members in accessing health related services and overcoming barriers to obtaining needed medical care and social services.
• Continuously learns about community resources and provides referrals to patients / members and their families as appropriate.
• Provides assistance, documents activities, plan of care, and results in an effective manner while strictly adhering to the policies and procedures in place to improve access to healthcare by building an equity-focused, comprehensive, high functioning, and affordable system of care.
• Attends trainings, continuing education, and professional development programs to maintain active Community Health Worker Certification.
• Provides information, education, and support in accessing the patient portal (MyChart).

Qualifications

Education :

• High School Diploma or equivalent required.
• Associate's Degree preferred.
• Bachelor's Degree preferred.

Experience :

• One (1) year of experience working in a multi-cultural, community based setting preferred.
• Bilingual in English, Spanish, and / or other foreign language preferred.

Licenses and Certifications :

• Certification by the TX Department of State Health Services as a Promotora / CHW required upon hire.
• CPR - Cardiac Pulmonary Resuscitation through the American Red Cross or American Heart Association preferred.

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