Works within the community providing outreach to patients with complex medical and social needs. Acts as a resource to assist patients in navigating the health care system. The role involves orienting and assessing new Community Health Workers, assisting in the identification and outreach of medically complex patients, and collaborating with the multidisciplinary team in the development and implementation of care plans. This position engages patients through various means including phone calls, home visits, hospital visits, and accompanying patients to provider appointments. It also involves identifying gaps in care, connecting members with resources, facilitating telemedicine visits, performing disease-specific education, conducting medication reviews, and safety evaluations in patients' homes. The worker facilitates adherence to treatment plans by early identification and resolution of gaps in care and communicates concerns to the clinical team and manager. Participation in multidisciplinary team conferences and reinforcement of treatment plans under the direction of a Case Manager and Licensed Social Worker are also key aspects.
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Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
Number of Employees
5,001-10,000 employees