Enhanced Care Management Community Health Worker

Organizational Description

The Community Health Center Network (CHCN) is a partnership between eight health service organizations in Alameda County, whose mission is to provide a comprehensive range of professional health services in a manner respectful of the community values and traditions. CHCN is a nonprofit corporation, serving as an agent for its member health service organizations. CHCN also provides administrative support to the Alameda Health Consortium (AHC).

Position Title:Enhanced Care Management (ECM) Community Health Worker (CHW)

Department: Care Neighborhood Enhanced Care Management

Reports To: ECM Health Services Supervisor

Classification: Non-Exempt

Status: Full-Time Regular

POSITION SUMMARY

Care Neighborhood (CN) Enhanced Care Management (ECM) is an innovative program to support and empower identified high-risk, high-needs patients to improve their health outcomes. The multidisciplinary team (RN, MD, LCSW, and CHWs) works together to support patients and address the social drivers that impact health, such as, food, housing, transport, and financial resources.

The Community Health Worker (CHW) will work with eligible hard-to-reach patients of any CHCN member health center. There will be a period of virtual orientation with the CN ECM central team at CHCN. After this, the CHW will work remotely and in the field when visiting patients at home, in the hospital, or in the community. This role is predominantly a remote position. Activities include outreach and engagement, development of the care plan, linkage of the patient to resources (food, housing, transport, financial) as well as linking the patient to care within the health center.

The Community Health Worker is a trusted member and/or a person who has a close understanding of the community served in the delivery of health-related services through either working directly with providers or their partner organizations. CHWs build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy.

ESSENTIAL POSITION FUNCTIONS

The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may perform other duties as assigned.

● Advocate for patients and help them achieve their best health.

● Communicate well with patients, document clearly in the medical record and interface with medical providers to advocate for the patient.

● Ability to de-escalate tense situations; training in de-escalation provided within 6 months of hire.

● Must have the ability to maintain professional boundaries, including exercising objectivity and confidentiality, while building trusting relationships with patients, and staff.

● Must be able to exercise good judgment and common sense, based on analysis, evaluation, and risk assessment in determining what to handle without help, and when to ask for guidance in prioritizing from supervisor.

● Conduct outreach, assessments, and care plans that are person-centered.

● Schedule health-related transportations and other social supports, that often exist in a broken-system with many challenges, that are barriers to access to care.

● Employ evidence-based behavior change strategies that promote and encourage positive behavior change.

● Serve as a liaison between the community, healthcare, and social services.

● Meet departmental review and documentation standards for work assignments.

● Report incidences of child or elder abuse, neglect, or threats of harm to authorities, as required.

● Adhere to the policies and procedures of CHCN and CHCN health centers.

● Build and maintain appropriate relationships on behalf of CHCN.

● Support a positive work environment and foster teamwork.

● Excellent communication, organizational, and time management skills with the ability to meet tight timeframes.

● Drives and consistently achieves results even under tough circumstances.

● Constructive in interpersonal relationships.

HIPAA Designated Access

“For the purposes of the job duties of this position, the person in this position requires access only to the following HIPAA protected information data sets.”

SUPERVISORY RESPONSIBILITIES

None

MINIMUM QUALIFICATIONS

Competencies

● Competent leadership and administrative skills.

● Good communication and customer relations skills; ability to work well with a team and independently.

● Sound decision-making skills including problem solving, critical thinking, and good judgment.

● Ability to make cold calls to patients and area resources.

● Professional demeanor.

Essential Requirements

● Bachelor’s degree or a combination of High school diploma/AA with 3 years in a community-based health care service capacity.

● At least three (3) years of progressively responsible work experience in a community-based setting.

● Bilingual preferred in the following languages: Spanish and/or Cantonese or Mandarin.

● Be creative and mature with a “can do”, proactive attitude and an ability to continuously “scan” the environment, identifying and taking advantage of opportunities for improvement.

● Commitment to working directly with low-income communities with diverse backgrounds, in a helpful, supportive manner.

● Strong computer literacy and familiarity with electronic medical record and supporting applications, such as EPIC and Tableau.

● In-depth knowledge of and proficiency in case management, health issues, and the health care system.

● Manages complex and sometimes contradictory information to effectively solve problems.

● Flexible and adaptable to a rapidly changing program that continues to shift gears at the State and local level.

● Understands data and analytics relevant to case management and monitoring and reporting of productivity to meet required outcomes.

● Ability to learn quickly and retain complex information.

● Travel to work assignments as needed, a valid current license and appropriate individual automobile insurance must be maintained.

● Knowledge of East Bay health and social service resources.

General CHCN roles

· Fosters an environment that promotes trust and cooperation among clients, clinical care team, and CHCN staff.

· Enforces policies and procedures, including maintenance of client confidentiality, to ensure that the principles of CHCN are implemented.

· Accountable for participating in decision-making processes and understanding the outcome(s).

· Understands the values and principles of CHCN and applies them in work responsibilities.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit and use hands to manipulate, handle, or feel. The employee is frequently required to talk or hear. The employee is frequently required to stand; walk; reach with hands and arms and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus.

WORKING CONDITIONS AND ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly exposed to both an inside/outside environment.

The Community Health Center Network is an Equal Opportunity Employer.