CHRONIC CARE MANAGEMENT COMMUNITY HEALTH WORK

Harmony Health Care Long Island•Hempstead, NY

3d•$23 - $25

About The Position

The Chronic Care Management Community Health Worker (CCM CHW) supports the Chronic Care Management program by serving as the key liaison between patients and the care team. This role focuses on maintaining consistently monthly patient contact, reinforcing care plans, and relaying patient needs and updates back to the interdisciplinary team. The CHW works under the guidance of providers and nursing staff to support patient engagement, self-management, and adherence to treatment plans.

Requirements

High School Diploma or equivalent experience required.
At least one year of experience in healthcare or case management is required.
Working knowledge of computer software and electronic health records.
Basic computer skills (Microsoft Office, data entry).
Bilingual Spanish or Creole required.

Nice To Haves

Bachelor's degree in health-related field, Certified Medical Assistant (CMA), Certified Professional in Healthcare Quality (CPHQ) or similar certifications preferred.
Experience working with patients with chronic conditions preferred.
Understanding chronic disease management concepts preferred.
Familiarity with care coordination or population health workflows preferred.

Responsibilities

Identify eligible patients, introduce CCM services, and enroll in CCM program by obtaining consent.
Conduct consistent monthly outreach telephonically.
Build rapport and maintain ongoing engagement with enrolled patients.
Perform follow-up calls related to chronic condition management.
Identify and escalate barriers to care (appointments, medications, social needs).
Document all patient interactions in accordance with CCM requirements.
Review Care Plans with patients to ensure understanding.
Reinforce individualized goals, self-management strategies, and next steps.
Identify barriers to adherence and escalate concerns to the care team.
Identify when updates are needed and notify providers.
Review medication adherence with patients (non-clinical).
Support patients in understanding prescribed regimens and routines.
Encourage chronic disease self-management techniques.
Participate in team huddles with providers and nursing staff.
Receive direction and task prioritization from clinical and care coordination leadership.
Maintain ongoing communication with assigned Nurse Care Manager.
Coordinate care across providers, specialists, and community resources.
Track referrals, lab results, and follow-up needs.
Support transitions of care activities by following up with patients discharged within 48-business hours of notification and assisting with scheduling post-discharge care.
Focus on closing Gaps in Care (GIC).
Participate in monthly Multidisciplinary Team (MDT) meetings.
Manage patient status and monitor progress towards health goals.
Gather and report patient updates, concerns, and barriers.
Contribute to team-based strategy development for complex patients.
Assist in implementing agreed-upon care strategies with patients.
Document CCM activities in the electronic health record (EHR).
Track accurate time spent on qualifying CCM services.
Ensure documentation supports billing requirements.
Ensure CCM services align with regulatory requirements.
Participate in audits and quality improvement activities.
Maintain HIPAA compliance.
May be assigned other tasks and duties reasonably related to job responsibilities.