Community Health Worker - Population Health

Duties and Responsibilities:

·  Conveys the purpose of the program to the patients and the impact that the service will have on their medical care and outcomes.

·  Helps patients develop health management plans and goals through assessment tools to identify individual patient needs.

·  Follows-up with health management plan and goals with both the patient and providers.

·  Coaches patients in effective management of their chronic health conditions and self-care habits, such as preventing and managing uncontrolled diabetes.

·  Assist patient in understanding plan of care, medications, self-management activities and instructions.

·  Documents patient vital signs, activities, plan of care and results in the electronic medical record in an effective manner while strictly adhering to the policies and procedures in place.

·  Works collaboratively and effectively within a team.

·  Establishes positive, supportive relationships with participants and provide feedback.

·  Helps patients in utilizing resources, including scheduling appointments, and assisting with completion of applications for programs for which they may be eligible for to improve health outcomes.

·  Assists individuals with self-management of chronic health conditions and medication adherence

·  Assists patients in accessing health related services and overcoming barriers to obtaining needed medical care, social determinants of health and services.

·  Facilitates communication and coordinate services between providers.

·  Motivates patients to be active, engaged participants in their health.

·  Works effectively with people (staff, clients, providers, agencies, etc.) from diverse backgrounds in reducing cultural and socio-economic barriers for patients.

·  Conducts intake assessments and educational and health maintenance sessions at the convenience of the patient in the patient home, office, through telephone or other designated area.

·  Builds and maintains positive working relationships with the patients, providers, nurse case managers, agency representatives, supervisors and office staff.

·  Continuously expands knowledge and understanding of community resources, services and programs provided in the community as well as within Tandem Health.

·  Confers as needed and on a timely basis with health center providers regarding patient issues and concerns.

·  Collects, reports, and enter data for purposes of evaluating CHW activities and completing grant reporting.

·  Identifies patients at risk for poor adherence.

·  Communicates with patients after a hospital discharge to follow up on treatment plans.

·  Helps patients connect with transportation resources.

·  Acts as a patient advocate and liaison.

·  Attends regular staff meeting, trainings and other meetings as requested.

·  Manages assigned caseload of patients.

·  Other duties as assigned.

Qualifications:

Education and Experience:

·  High School Diploma or its equivalent required.

·  Experience working as a medical assistant in a primary care setting preferred.

·  Experience working in a community-based setting for at least 1-2 years preferred.

·  Must be willing to seek Certification for Community Health Worker in accordance with the South Carolina state-approved certification process.

·  Current South Carolina driver's license required. Driving record must meet Tandem Health insurance standards upon employment, and continually thereafter.