Community Health Worker - Primary Care - 65 Plus-Savannah

Ochsner Health•Ridgeland, SC

1d•Onsite

About The Position

This job conducts care management focused on social determinants and chronic disease management, including mental health assistance and management. Conducts health education, resource referrals, and community outreach including inter/intra agency collaboration. Serves as a bridge between patient needs and care team guidance. Mentors and trains CHWs in training. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential duties. This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities. Contents are subject to change at the company’s discretion.

Requirements

Associate’s degree
2 years’ experience in Social Service, Case Management or Chronic Disease Care Management
A Bachelor’s degree will be accepted in lieu of 2 years’ work experience
Community Health Worker training certificate must be obtained within 1 year of hire
Must have computer skills and dexterity required for data entry and retrieval of information.
Effective verbal and written communication skills and the ability to present information clearly and professionally.
Must be proficient with Windows-style applications, various software packages specific to role and keyboard.
Ability to communicate with individuals to educate and facilitate problem-solving.
Strong interpersonal skills and ability to work with community members from diverse backgrounds.
Case management skills and ability to plan treatments.
Active facilitator in interdisciplinary care planning and coordination.
Working knowledge and confidence in utilizing health coaching and motivational interviewing skillsets.
Utilize data and reports in care coordination activities and tracking patient progress.
Ability to work independently.
Organizational skills and ability to maintain a database.

Nice To Haves

Bachelor’s degree in Public Health, Social Work, Education, Psychology or a related field

Responsibilities

Assists with chronic care management by providing patient follow-up services and documenting patient outcomes, educating patients, providing treatment options, and facilitating support groups.
Works with patients both in person and telephonically to initially assess and address patient needs, with ongoing monitoring of patient throughout continuum of care.
Engages in intra- and inter-agency collaboration by coordinating patient care across health systems and navigates community resource and advocates for patients and community members.
Provides community health education and outreach to inform individuals, families and local agencies about health and wellness service; coordinates group health educations sessions and assists with health fair events.
Provides behavioral health counseling and support as part of an established treatment plan.
Provides culturally aware social support and assistance with capacity building/motivational support.
Acts as a health care coach including self-management support, goal setting, and individualized action planning.
Develops, tracks and maintains database of community outreach activities for grant tracking and reporting.
Pulls and reviews reports to monitor care coordination activities and tracks patient progress and outcomes.
Acts as a preceptor to CHWs to adequately train them in all job functions, while mentoring/consulting with new CHWs to help settle into their role.
Adapts behavior to the specific patient population, including but not limited to respect for privacy, method of introduction to the patient, adapting explanation of services or procedures to be performed, requesting permissions and communication style.
Performs other related duties as required.
Remains knowledgeable on current federal, state and local laws, accreditation standards or regulatory agency requirements that apply to the assigned area of responsibility and ensures compliance with all such laws, regulations and standards.
This employer maintains and complies with its Compliance & Privacy Program and Standards of Conduct, including the immediate reporting of any known or suspected unethical or questionable behaviors or conduct; patient/employee safety, patient privacy, and/or other compliance-related concerns.