Community Health Worker

The Wright Center Medical Group•Scranton, PA

28d

About The Position

The Community Health Worker (CHW) works closely with medical providers, primary care teams, and social services agencies to provide short-term care coordination. The CHW helps patients connect with resources and supports their health and general well-being through education and coordination of care and services. Community outreach, including home visits, health screenings, and events, may be required. The CHW assists patients in home, community, and health center settings; helps patients identify social and economic issues affecting their health; supports development of health and social management plans; and coordinates communication and services among patients, providers, care managers, and community agencies. The role includes patient education, advocacy, outreach and enrollment, documentation, follow-up, and connecting patients to resources and programs. The CHW participates in team huddles, extended access coverage, and cross-coverage of other locations and service lines.

Requirements

High school diploma or GED.
At least 3 years of experience directly related to the duties and responsibilities specified.
Current BLS certification.
Complete AHEC training for CHW certification within one year of employment.
Apply for the CCHW PA certificate after completing CHW training and within 13 months of hire, and obtain it within 15 months of hire.
Meet The Wright Center for Community Health and its affiliated entity The Wright Center for Graduate Medical Education EOS© People Analyzer Tool.
Mission-oriented, professional representation of the enterprise, and organizational pride.
Strong interpersonal and communication skills and ability to work effectively with a wide range of constituencies in a diverse community.
Knowledge of community agencies and resources.
Working knowledge of the patient-centered medical home model and multi-system outreach programs related to health care delivery, clinical education, and health-related services.
Ability to plan, implement, and evaluate individual patient care plans.
Knowledge of transportation and other barriers to care patients may encounter.
Ability to communicate medical information to health care professionals and care coordinators by telephone.
Basic computer skills.
Skill in organizing resources and establishing priorities.
Creative and analytical thinking.

Nice To Haves

Experience working in the EOS® model (strongly preferred).
Completed degree(s) from an accredited institution preferred.
Bilingual skills highly desired.

Responsibilities

Assist patients in their homes, community, or health center setting.
Explain the program’s purpose to patients and its potential impact on their well-being.
Help patients identify socioeconomic issues affecting their health and develop health and social management plans and goals.
Document patient encounters and contacts in the EMR, submit monthly reports, and maintain comprehensive electronic patient files.
Educate patients about appropriate Emergency Department use and alternatives.
Coach patients in managing chronic health conditions and self-care, and help them understand care plans and instructions.
Motivate patients to participate actively in their health and well-being.
Connect with Hot spotting Teams to link patients with enabling services.
Provide support and advocacy during initial medical visits or when needed to ensure medical needs and referrals are communicated.
Follow up with patients and providers regarding health and social services plans; go to the hospital as needed.
Maintain knowledge of community resources and services.
Help patients access community resources, including housing, food, clothing, prenatal classes, parenting resources, and mental health services.
Help patients use community services, schedule appointments with social services agencies, and complete eligible program applications.
Facilitate communication and coordinate services between providers and patients.
Coordinate and monitor services, including tracking patient compliance with care plan objectives.
Work effectively with the team and build supportive relationships with participants, patients, providers, care managers, medical residents, and office staff.
Help reduce cultural and socioeconomic barriers between patients and institutions.
Provide self-pay patients with options for paying for services.
Explain health center resources and programs, including the sliding fee discount program, Good Faith Estimate, outreach and enrollment programs, language services, and after-hours coverage.
Follow applicable emergency procedures, including understanding the role and responsibilities for helping coworkers and patients reach safety and knowing the availability and location of SDS and 990 binders.
Communicate positively with patients, visitors, and staff in support of The Wright Center’s mission.
Attend weekly huddles and morning and afternoon mini huddles.
Participate in rotation of extended access hours, including late nights, weekends, and holidays.
Cross-cover other locations and service lines to support continued patient access.
Understand insurance dynamics, including copays, coverage, and navigation.
Obtain and maintain Pennie Assister training certification to conduct outreach and enroll patients in appropriate insurance within 90 days of employment.
Conduct outreach and engage patients with positive PCRT screenings and outstanding barriers to care.
Capture patient demographic information, especially barriers to care, to help provide an overall picture of the patient population.
Perform miscellaneous job-related duties as assigned.
Complete AHEC training for CHW certification within one year of employment; apply for the CCHW PA certificate after training and within 13 months of hire, and obtain it within 15 months of hire.