Acts as a bridge between community residents and healthcare systems to reduce health disparities and improve access to services. Responsibilities include assessing social needs, developing care plans, and connecting patients with community resources.
Requirements summary
Requires a Community Health Worker and Basic Life Support certification within a short timeframe after hire. A bachelor's degree in a social science field and bilingual proficiency in Spanish are highly preferred.
The Community Health Worker (CHWs) shall serve as front-line health workers who come from the communities they serve which aid in building trust and vital relationships with the residents of their community. This trusting relationship enables CHWs to be effective links between their own communities and systems of health care and social services. The goal of the CHW is to lower health disparities in their community by providing access to services, improving the quality and cultural competence of care, creating an effective system of chronic disease management, and increasing the health knowledge and self-sufficiency for clients.
Essential Functions
Serves as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources.
Connects clients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs.
Assists patients with referrals, follow-up, and completing applications for services.
Works with patients to plan and monitor care.
Assesses patient’s unmet health and social needs.
Assists in developing a care plan with the patient, family/care giver(s) and providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate).
Monitors adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed.
Creates ongoing processes for patient and family/caregiver(s) to determine and request the level of care coordination support they desire at any given point in time.
Reviews currently existing programs and health initiatives to ensure they’re up-to-date, effective and safe for their intended audience(s).
Reaches out to clients using a variety of mediums (phone, Zoom, in-person) to check up on their progress, answer questions, make personalized recommendations and changes to their programs if necessary.
Completes administrative tasks on an ongoing basis to ensure proper and organized record keeping, working with staff members when/if necessary.
Assists in maintaining an efficient, safe, secure, orderly, and aseptic environment of care for all patients and employees.
Establishes a close relationship with the clients as necessary for comprehensive care.
Has good problem-solving skills to effectively identify and address community health needs.
Facilitates patient access to appropriate medical and specialty providers
Educates patient and family/caregiver(s) about relevant community resources
Facilitates and attend meeting between patient, family/caregiver(s), care team, payer, and community resources, as needed.
Cultivates and supports primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-and referrals.
Assists with identification of “high-risk” patients (the chronically ill and those with special health care needs), and add these to the patient registry (or flag in EMR.)
Attends all Community Health Worker training courses/webinars and meetings.
Provides feedback for the improvement of the Care Coordination Program.
Assists members with social services applications such as SNAP, Food Stamps, Disability, Medicaid, TANF, Medicare, Marketplace Insurance, etc.
Performs all other duties as assigned.
Must be able to deal with stress while maintaining composure.
Follows and adheres to TRMC vaccine policy(s) mandated by the Centers for Medicare & Medicaid Services (CMS).
Work Experience
Experience working with high-risk, vulnerable, or uninsured population highly preferred.
Bachelor’s Degree in Social Work, Psychology, Public Health or Social Services preferred but not required.
Bilingual in Spanish highly preferred.
Education
Community Health Worker Certification within 90 days of hire.
Basic Life Support within 30 days of hire.
Physical Demands and Work Environment
Lifting/Carrying Pushing/Pulling
Lbs. % Time Lbs. % Time
1-10 34-66 1-10 34-66
11-20 0-33 11-20 0-33
21-50 0-33 21-50 0-33
51-75 0-33 51-75 0-33
76-100 0-33 76-100 0-33
Movement % Time
Bend/Stoop/Twist 0-33
Crouch/Squat 0-33
Kneel/Crawl 0-33
Reach above Shoulder 0-33
Reach below Shoulder 0-33
Repetitive Arm None: Repetitive Hand 0-33
Grasping 0-33
Squeezing 0-33
Climb Stairs None: Walking Uneven 0-33
Walking Even 34-66
Environment % Time
Indoors 67-100
Outdoors 0-33
Extreme Heat 0-33
Dusty None: Excessive Noise 0-33
Equipment % Time
Motor Vehicles None
Foot Pedals None
Extreme Heat None
Dusty None: Excessive Noise 0-33
Work near % Time
Machinery None
Electricity None: Sharps 0-33
Chemicals 0-33
Fumes 0-33
Heights None
Vision
Depth Perception Required: < 20" Required
Color Not Required
Peripheral Required: Endurance Hours at Once Total in 12HR
