Chronic Disease Community Health Worker (Bilingual-Spanish preferred)

St. Luke's University Health Network•Bethlehem, PA

About The Position

The Chronic Disease Community Health Worker (CHW) provides education based on priorities established through the Community Health Needs Assessment (CHNA) and helps patients navigate and access community services and resources. The CHW promotes healthy behaviors for chronic disease prevention and management, and supports nurses, providers, liaisons, case management, and the clinical care team through an integrated approach to education, community outreach, and partnerships. The role also provides social support, informal counseling, education, and advocacy for individuals and community needs. The CHW works with the Community Health and Diabetes Self-Management, Education and Support (DSMES) team to address patient and family needs, including navigation, care coordination, insurance connections, and social determinants of health. Under provider direction, the CHW provides disease-specific education, including diabetes and hypertension education, and maintains follow-up and resource connections. The role reports operationally under the direction of the Network Director Community Health Clinical Operations.

Requirements

High school diploma or GED required.
Complete a network-approved Community Health Worker/Care Coordinator training program within one year of hire or within one year of adoption of the job description.
One to two years of experience working in a community-based setting.
Knowledge of medical terminology required.
Complete 15 hours of diabetes management training within four months of hire.
Ability to meet the stated physical and sensory requirements, including sitting, standing, walking, frequent hand use, and occasional lifting and carrying objects up to 25 pounds.

Nice To Haves

Bachelor’s degree preferred.
Spanish preferred.

Responsibilities

Work with the Community Health and Diabetes Self-Management, Education and Support (DSMES) team to identify patients and families needing navigation, care coordination, insurance connection, or other assistance identified through a Social Determinants of Health assessment.
Follow requirements for the Diabetes Education Accreditation Program (DEAP).
Establish trusting relationships with patients and families and provide general support and encouragement.
Work with the healthcare team under the direction of the Network Director Community Health Clinical Operations to help ensure coordinated care.
Provide disease-specific education, including diabetes and hypertension education, in individual or group sessions under provider direction.
Provide ongoing follow-up and connect patients and families with resources.
Register, schedule, check in, and check out patients according to Electronic Health Record requirements, and accurately document encounters in EPIC.
Assess referral needs and determine eligibility for services according to government and local program guidelines.
Participate in in-services and continuing education programs to support professional development.
Serve as a professional role model and resource, providing guidance to co-workers.
Participate in department Quality Improvement activities.
Maintain confidentiality and ensure proper release of information.
Comply with Network and departmental policies for employee, patient, and environmental safety and follow reporting requirements.
Model the Network’s Service Excellence Standards of Performance when interacting with internal and external customers.
Demonstrate performance improvement in clinical care and outcomes, customer service, operational systems and processes, and safety, as appropriate.
Use resources effectively and efficiently and demonstrate financial responsibility and accountability.
Comply with Network and departmental attendance and dress-code policies.
Perform other duties as assigned.