POSITION PURPOSE
Serves as a bridge between the health system and patients, particularly patients with Medicare and/or Medicaid and patients with identified social needs. Works to promote, maintain, and improve health and well-being through informal support and counseling to their patients. Uses culturally appropriate outreach, support, and navigation to help patients access health care and address identified social needs.
Plays a key role in building individual capacity by increasing patient’s health knowledge and self-sufficiency through a range of activities such as health education, goal setting, motivational interviewing, and advocacy. Works collaboratively with other healthcare team and community-based providers to improve patient health outcomes and reduce racial, ethnic, and economic disparities in those outcomes.
ESSENTIAL FUNCTIONS:
Our Trinity Health Culture: Knows, understands, incorporates & demonstrates our Trinity Health Mission, Values, Vision, Actions & Promise in behaviors, practices & decisions.
Work Focus: Delivers high-value services to patients, such as coordination of care, accompaniment to appointments, and outreach, in clinical and community-based settings. Works with an assigned patient caseload to provide support, advocacy, and referrals to community-based services. Assesses patients for social needs and barriers to available resources and services. Helps patients navigate and gain access to appropriate health care/social services and other community resources. Provides basic education regarding health promotion to increase understanding and encourage adopting healthy behaviors. Shares insight and expertise such as patients’ customs/beliefs with providers and works collaboratively to promote culturally appropriate services.
Process Focus: Utilizes multiple system applications for caseload management, data collection, and reporting. Uses Electronic Health record and embedded tools for care coordination and documentation. Uses applicable resources, services, and processes to complete relevant referrals and applications in a timely manner. Collaborates on performance improvement activities as indicated by program outcomes and patient experience. Incorporates basic knowledge of Trinity Health policies, practices & processes to ensure quality, confidentiality & safety are prioritized. Demonstrates knowledge of departmental processes & procedures & ability to readily acquire new knowledge.
Communication: Employs effective & respectful written, verbal & nonverbal communications; Develops an environment of mutual confidence & trust through collaborative relationships; Effectively communicates goals, standards, program expectations, service performance & how the work serves Trinity Health objectives. Serves as a liaison between providers and patients to improve communication and coordination of services. Provides support to patients via phone and in-person interactions at patient’s home, community, or clinic setting.
Environment: Performs work in a caring, collaborative & safe manner that complies with regulatory standards. Maintains a safe, functional & organized workspace environment. Stewards productive use of resources (e.g., people, financial, equipment, supplies, materials) to achieve assigned commitments, experiences & quality standards. Responsible for continuous role-based self-development & leadership growth. Self-monitors & initiates corrections and/or seeks assistance or guidance when needed.
Maintains a working knowledge of applicable Federal, state & local laws/regulations, Trinity Health Integrity & Compliance Program & Code of Conduct, as well as other policies, procedures & guidelines to ensure adherence in a manner that reflects honest, ethical & professional behavior & safe work practices.
This position is a hybrid position where the CHW may work partially remotely and partially in-office. There will be significant telephone communication and coordination. There will be occasions when the CHW will make in-home calls for patients who require community assistance.
Bi-lingual in Spanish and English a big plus.
Our Commitment to Diversity and Inclusion
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.