Family Health Worker W

Montefiore Health System•New York, NY

About The Position

The Community Health Worker Institute at Montefiore Einstein is an Institute of excellence designed to help patients navigate social determinants of health. Family Health Workers (also known as Community Health Workers) are integrated members of clinical healthcare teams across the health system. They help patients overcome challenges, advocate for themselves, and remain engaged in clinical care by connecting them with clinical and community resources. These resources may address food access, housing quality, affordable housing, utility shutoffs, evictions, and connections to healthcare team members or services. The Family Health Worker follows up with patients, documents and reports outcomes, and supports patients at multiple clinical sites, traveling to each site weekly. The role also includes home visits, service-provider accompaniment, and individually tailored education and follow-up to support healthy behaviors and use of health and social support services.

Requirements

High school diploma or GED.
At least 1 year of work experience.
Ability to use Microsoft Office Suite, the Epic electronic medical record, REDCap data reporting system, and virtual meeting software such as Microsoft Teams and Zoom.
Ability to use a fax machine, telephone, and photocopier/scanner.

Responsibilities

Assess patients’ social needs and link them to needed services.
Follow up with patients to improve engagement and ensure challenges have been addressed and needs are met.
Conduct intensive follow-up with high-risk patients to improve clinical outcomes and communicate patient barriers, risks, and complications to the care team.
Share current resources, eligibility criteria, and information for navigating health and social needs; organize required documents, complete applications, and schedule appointments.
Track and document patient contacts, services provided, and follow-up outcomes.
Build and maintain positive working relationships with social service agencies, community-based organizations, and community-based programs.
Explain the role and services of the CHW Institute and its staff to internal and external stakeholders, community members, and patients.
Complete ongoing training to improve patient engagement skills, content-area knowledge, and navigation.
Conduct virtual and in-person home visits and accompany patients or families with the highest needs to service providers.
Provide individually tailored education and follow-up to support healthy behaviors and use of health and social support services.
Support patients at multiple clinical sites and travel to each site weekly.