Community Health Worker

InnovaCare • Orlando, FL

10d • Hybrid

About The Position

The Community Health Worker (CHW) does Care Coordination & Social Services. This position assists the clinical operations/care management teams. Under supervision of the care management supervisor, the CHW works with medical providers, primary care teams, and social agencies to provide short-term care coordination and connection to resources and support programs for patients to improve their health and well-being. The CHW is responsible for the initial biopsychosocial assessment and performs telephonic, face-to-face, at the clinic or patient’s home. This is focused on the following areas: home visits, safety, support system, clinical or medical, identifying issues related to cognitive behavior changes, and informing the Supervisor. The CHW creates a plan to address patients’ social needs.

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.
• Assist 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.
• 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.
• 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: Entry Level
• Education Level: Associate degree