Community Health Worker

InnovaCare Health • Jacksonville, FL

7d • Hybrid

About The Position

The Community Health Worker (CHW) provides services including facilitating the patient’s psychosocial adjustment along the continuum of care and transition to the next level of care. They develop effective relationships with the patient, family, and case managers, engaging the patient/family and collaborating, advocating, and problem-solving. The CHW assists patients in their homes and community, communicates the program’s purpose, educates on Advance Directives, helps complete forms, and provides information on POA. They assist patients in care management with health-related social determinants and financial, emotional, and social issues, helping patients identify socio-economic matters affecting their overall health and develop health/social management plans and goals. The CHW provides community linkage for patients and families experiencing significant emotional, social, environmental, or financial stress to hospitalization, acute or chronic illness, and who need help meeting their continuing care needs. They screen for the Falls Prevention Program and demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served with a thorough understanding of the principles of growth and development over the life span. The CHW demonstrates awareness of the medical/legal issues of patient rights and compliance with standards of regulatory and accrediting agencies. They document all client encounters and contracts made on behalf of clients, complete and submit monthly reports, and document activities, service plans, and outcomes effectively achieved by patients. The CHW educates the client on the Emergency Room’s proper use and provides information for alternatives. They coach patients in the effective management of their chronic health conditions and self-care, assist patients in understanding care plans and instructions, and motivate patients/clients to be active and engaged participants in their health and overall well-being. The CHW provides support and advocacy during an initial home visit or when necessary to ensure patients' medical needs and referrals required are being conveyed, and follows up with both clients and providers regarding health/social services plans. They ensure patients and families have access to prescription, durable medical equipment (DME), and other services as identified. The CHW facilitates communication and coordinates services between providers and patients, comprehensively tracking clients' compliance with care plan objectives. They travel to clinics or patient homes, community locations, agencies, and other outreach destinations and perform miscellaneous job-related duties as assigned.

Requirements

• Strong interpersonal and communication skills and the ability to work effectively with various constituencies in a diverse community.
• Knowledge of community agencies and resources.
• Working knowledge of multi-system outreach programs related to health care delivery, clinical education, and health-related services.
• Ability to plan, implement, and evaluate individual client care plans.
• Knowledge of transportation and other barriers to caring for the client may encounter.
• Ability to communicate medical information to health care professionals and care coordinators over the telephone.
• Skill in personal computers and related software applications, including e-mail.
• Skill in organizing resources and establishing priorities.
• Creative and analytical thinking.
• Travel expected about 40% of the time.
• Car and valid driver’s license.

Nice To Haves

• Associate degree in Business Administration or Human service, Paramedic or Certified Nursing Assistant, and successful completion of a Community Health Worker formal training program such as from a college or other educational institution is preferred.
• Medical terminology and background preferred.
• Can write and speak in English and Spanish.

Responsibilities

• Provides services including facilitating the patient’s psychosocial adjustment along the continuum of care and transition to the next level of care.
• Develops effective relationships with the patient, family, and case managers.
• Engages the patient/family and collaborates, advocates, and problem-solves.
• Assists patients in their homes and community and communicate the program’s purpose.
• Educates on Advance Directives, helps complete forms, and provides information on POA.
• Assists patients in care management with health-related social determinants and financial, emotional, and social issues.
• Helps patients identify socio-economic matters affecting their overall health and develop health/social management plans and goals.
• Provides community linkage for patients and families experiencing significant emotional, social, environmental, or financial stress to hospitalization, acute or chronic illness, and who need help meeting their continuing care needs.
• Screens for Falls Prevention Program.
• Demonstrates knowledge and skills necessary to provide care appropriate to the age of the patients served with a thorough understanding of the principles of growth and development over the life span.
• Demonstrates awareness of the medical/ legal issues of patient rights and compliance with standards of regulatory and accrediting agencies.
• Documents all client encounters and contracts made on behalf of clients; completes and submits monthly reports.
• Documents activities, service plans, and outcomes effectively achieved by patients.
• Educates the client on the Emergency Room’s proper use and provides information for alternatives.
• Coach patients in the effective management of their chronic health conditions and self-care.
• Assists patients in understanding care plans and instructions.
• Motivates patients/clients to be active and engaged participants in their health and overall well-being.
• Provides support and advocacy during an initial home visit or when necessary to ensure patients' medical needs and referrals required are being conveyed.
• Follows up with both clients and providers regarding health/social services plans.
• Ensures patients and families have access to prescription, durable medical equipment (DME), and other services as identified.
• Facilitates communication and coordinate services between providers and patients.
• Coordinates and monitors services, comprehensively tracking clients' compliance with care plan objectives.
• Travels to clinics or patient homes, community locations, agencies, and other outreach destinations.
• Performs miscellaneous job-related duties as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree