Chronic Disease Community Health Worker

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

About The Position

St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care. The Chronic Disease Community Health Worker (CHW) will be responsible to provide education according to priorities established through our Community Health Needs Assessment (CHNA) while assisting patients to navigate and access community services and resources They will promote healthy behaviors for chronic disease prevention and management. The Chronic Disease CHW supports nurses, providers, liaisons, case management, and the clinical care team with an integrated approach to education and community outreach and partnership and provides social support, informal counseling, and education while advocating for individuals and community needs.

Requirements

High School Graduate/GED required; Bachelors Preferred.
Successful completion of a network approved Community Health Worker/Care Coordinator training required within one year of hire or within one year of this job description adoption.
1-2 years of experience working in a community-based setting.
Knowledge of medical terminology required.
Fifteen hours of training in diabetes management required within four months of hire date.

Nice To Haves

Spanish preferred.

Responsibilities

Work in conjunction with the Community Health and Diabetes Self- Management, Education and Support (DSMES) team to identify patients/families requiring assistance in navigation, care coordination, insurance connection, and additional needs identified in Social Determinants of Health (SDOH) Assessment.
Follow requirements for the Diabetes Education Accreditation Program (DEAP).
Responsible for establishing trusting relationships with patients and their families while providing general support and encouragement.
Work closely with healthcare team, under the direction of the Network Director Community Health Clinical Operations to help ensure patients have coordinated care.
Provide disease-specific education during 1:1 or group sessions with patients under the direction of the department’s providers. This includes but is not limited to diabetes and hypertension.
Provide ongoing follow-up and resource connection with patients/families.
Register, schedule, check-in, and check-out patients according to Electronic Health Record (EHR) requirements.
Complete accurate documentation of all encounters in EPIC.
Assess the needs of referrals and determine eligibility for services, according to government and local program guidelines.
Maintain responsibility for own development through active participation at in-services and/or continuing education programs.
Function as a professional role model and resource person providing guidance to co-workers.
Participate in department Quality Improvement activities.
Maintain confidentiality of all materials handled within the Network/ Entity as well as the proper release of information.
Comply with Network and departmental policies regarding issues of employee, patient and environmental safety and follows appropriate reporting requirements.
Demonstrate/model the Network’s Service Excellence Standards of Performance in interactions with all customers (internal and external).
Demonstrate Performance Improvement in the following areas as appropriate: Clinical Care/Outcomes, Customer/Service Improvement, Operational System/Process, and Safety.
Demonstrate financial responsibility and accountability through the effective and efficient use of resources in daily procedures, processes and practices.
Comply with Network and departmental policies regarding attendance and dress code.
Other duties as assigned.