Req#: R34706
Category(s): Allied Health Clinical Professional, Community Health Worker
Full Time / Part Time: Full-Time
Shift: First
The Community Health Worker II (CHW II) is responsible for helping patients and their families navigate and access health and community services while adopting healthy behaviors. The CHW II works as a care team member through an integrated approach to care management and community outreach. The CHW II promotes, maintains, and improves the health of patients and their families by providing social support and informal counseling. The CHW II partners closely with different providers, patients, and outside organizations and is responsible for facilitating communication between patient and care teams and providing culturally appropriate health education and self-management support. Additionally, the CHW II will collaborate within a team-based care delivery model to improve the health and lives of our community members. The CHW II will participate in the development and implementation of innovative, cost-effective delivery system changes that proactively meet the complex needs of our patients, including efforts to manage their behavioral and social needs in addition to their medical care.
Job Responsibilities:1) Target and outreach, including home visits, to the most vulnerable and at-risk patients and establish positive and supportive relationships
2) Assist with medication adherence, reminding patients about upcoming appointments, arranging transportation assistance, and other services patients may need
3) Act as the primary contact person within the clinic for enrollment of new members and educate patients on all aspects of the healthcare delivery system
4) Complete Care Needs Screenings and all other applicable screenings to assess needs of the patient and provide appropriate referrals.
5) Coach patients in the effective management of their chronic conditions and self-care
6) Provides basic health education in individual or group sessions and helps patients develop health management plans that support the achievement of their individualized health and wellness goals
7) Help patients in identifying and utilizing community resources using approved community resource database, as well as demonstrated use of emr systems. Assist in scheduling and accompanying patients to appointments and assisting with the completion of applications for programs for which they may be eligible.
8) Facilitate communication and coordinate services between providers; work collaboratively and effectively within a multidisciplinary team.
9) Builds and maintains positive working relationships with the clients, providers, supervisors, and all staff
10) Continuously expand knowledge and understanding of community resources and services, public health prevention, and evidence-based intervention programs provided
11) Effectively works with people from diverse backgrounds, including translators, in reducing cultural and socio-economic barriers between clients and institutions.
12) Develops and implements culturally and linguistically tailored educational and support activities
13) CHW will alert the care team, RN, doctor, and any clinical staff with concerns related to patient diagnosis and tracking measures, which may include but are not limited to blood sugars, blood pressure readings, and any other measures ordered by PCP and provided by the patient
14) Documents activities, service plans, and results in appropriate data collection tools and/or EMR in a clear and concise manner
15) Assists in the education and mentoring of CHW 1 role and newly onboarded staff
16) Participates in identifying new resources for patients.
17) Communicates with community care partners to resolve any discrepancies regarding care plans and collaborates with community care partners on behalf of providers to coordinate patient services
18) Manage and refer patients to Mass Health designated programs and monitor patient outcomes
Preferred Education:Active enrollment in certified CHW program
Required Work Experience:2 years of Community-Based Organization related work experience
Preferred Work Experience:Experience working in a medical/healthcare setting
Skills and Competencies:Trust, respect, and dignity for all human beings are core values among CHWs, and are central to efforts to address clinical and community integration and the social determinants of healthBilingual skills are preferred and specific to the patient population being served.
Ability to use a computer, Microsoft Office, EMR, and proficient in accessing and searching the internet
Strong communication, writing, time management, and organizational skills
Willingness to work some weekend/evening hours depending on project and community needs, such as advocacy and community capacity-building activities
Demonstrated ability to work as an effective team member in a complex and fast-paced environment
Excellent interpersonal skills and demonstrated ability to interact professionally with culturally and educationally diverse staff and clients
Must have the ability to work with highly sensitive and confidential information
Reliable transportation with MA driver's license required
You Belong At Baystate
At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people.
DIVERSE TEAMS. DIVERSE PATIENTS. DIVERSE LOCATIONS.
Education:
GED or HiSET (Required)
Certifications:
Certified Community Health Worker – State of MassachusettsState of Massachusetts, Driver License – OtherOther
Equal Employment Opportunity Employer
Baystate 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, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.
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