Community Healthcare Network is seeking for a
Full-Time Community Health Worker/Population Health. The Community Health Worker/Population Health will provide short term care coordination for patients being discharged from hospitals or other inpatient settings back to the community to ensure a successful transition and reduce the likelihood of avoidable readmission to the hospital. This is a hybrid role with a mix of field-based work and remote work, as directed.
Job Function
Responsibilities include, but are not limited to:
- Extract data from internal and external data platforms to compile patient outreach lists, as directed.
- Conduct outreach to patients using multiple modes of communication, i.e., telephone, texting, video, and in-person.
- Assess patients’ appropriateness for CHW services, educate patients on the services, and enroll patients into the program when interested.
- Coordinate discharge planning with hospital clinical and social work staff.
- Complete patient assessments at program enrollment using structured interview tools, motivational interviewing techniques, and trauma-informed practices.
- Develop and maintain care plans in collaboration with patients using SMART goals.
- Participate in care conferences with the care team regarding the provision and coordination of services.
- Conduct regular visits with patients to assess new needs, discuss the status of SMART goals and update care plans.
- Work with the patients to provide health education, reconcile medications, monitor treatment adherence, assist with appointments, and assist with patient care plan tasks, as appropriate.
- Escort patients to internal and external healthcare or supportive service appointments in the community, as needed.
- Ensure patients are up to date on preventative healthcare services and screenings.
- Maintain consistent communication with patients and care team members.
- Maintain care records including documentation of outreach and visit notes, assessments, care plans, care conferences, relevant external patient records, and release of information forms.
What We Look For
- High School diploma or its satisfactory equivalent.
- Minimum of two (2) years of employment experience, healthcare and/or care management related experience preferred.
- Bilingual Spanish preferred.