Community Health Worker, Integra

Care New England Health System•Warwick, RI

57d•Hybrid

About The Position

The Community Health Worker is a member of the community health team, an interdisciplinary team comprised of Community Health Workers, In-Home team nurse care managers, schedulers, resource specialists, health navigators, and nurse practitioners. This role works closely with core team members to support patients dealing with complex medical, behavioral health, and/or substance issues, as well as social determinants of health, who require more intensive home and community-based intervention.

Requirements

High School diploma required with a combination of training and skills to effectively carry out responsibilities and assignments (such as previous experience working with patients in a community-based setting).
Must have Certification in Community Health Work or be working toward certification, must obtain certification within 12 months.
Experience working with primary care providers or in other healthcare settings.
The ability to travel to various locations in the state and reliable transportation is required.
Must possess a valid, current state-issued driver’s license, have reliable transportation and proof of current auto insurance required.

Nice To Haves

Associates or Bachelor’s degree in Social Work, Community/Public Health or related health sciences field.
Experience working with patients regarding managing their health, navigating systems, providing care coordination and health coaching.
Ability to speak a second language, Spanish preferred.

Responsibilities

Assist Integra In-Home patients in securing community resources identified through SDOH screening and in-home assessment.
Act as a liaison between the patient and community resources.
Perform SDOH screening and assessment of patients' needs to remain in the community.
Assist with the management of newly implemented chronic condition disease management programs for BCBS members.
Assess patient needs, offer community resources and referrals, provide navigation, support, care coordination, and ongoing case management.
Visit patients in their homes and communities, providing culturally sensitive health information to improve health literacy.
Facilitate patient decision-making and self-management to help patients engage in their overall health and achieve their health goals.
Track patient-related activities, monitor, and document progress.
Collaborate with the primary care team to promote patient-centered care and participate in multidisciplinary patient-centered team meetings.
Maintain frequent contact with community agencies on behalf of patients, networking and collaborating on resource identification to improve overall population health.