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.

Community Healthcare Network jobs

Community Health Worker/Population Health