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    Community Health Worker - New York, United States - Community Healthcare Network

    Community Healthcare Network
    Community Healthcare Network New York, United States

    3 weeks ago

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    Description

    The Population Health Community Health Worker will provide short term care coordination for patients being discharged from hospitals or other inpatient settings back to the community to ensure a successful transition and reduce the likelihood of avoidable readmission to the hospital. The CHW-PH will connect patients to healthcare and social services to address their complex medical and social needs to improve overall health and wellbeing. This is a hybrid role with a mix of field-based work and remote work, as directed.

    JOB FUNCTION

    Responsibilities include, but are not limited to:

    • Extract data from internal and external data platforms to compile patient outreach lists, as directed.
    • Conduct outreach to patients using multiple modes of communication, ie, telephone, texting, video, and in-person.
    • Assess patients' appropriateness for CHW services, educate patients on the services, and enroll patients into the program when interested.
    • Coordinate discharge planning with hospital clinical and social work staff.
    • Complete patient assessments at program enrollment using structured interview tools, motivational interviewing techniques, and trauma-informed practices.
    • Develop and maintain care plans in collaboration with patients using SMART goals.
    • Participate in care conferences with the care team regarding the provision and coordination of services.
    • Conduct regular visits with patients to assess new needs, discuss the status of SMART goals and update care plans.
    • Work with the patients to provide health education, reconcile medications, monitor treatment adherence, assist with appointments, and assist with patient care plan tasks, as appropriate.
    • Escort patients to internal and external healthcare or supportive service appointments in the community, as needed.
    • Ensure patients are up to date on preventative healthcare services and screenings.
    • Maintain consistent communication with patients and care team members.
    • Respond to patient and provider inquiries within 1 business day and other inquiries within two (2) business days.
    • Maintain care records including documentation of outreach and visit notes, assessments, care plans, care conferences, relevant external patient records, and release of information forms.
    • Obtain external patient records via electronic health records systems, secure email, or fax and upload the records into the patient's chart, assigning them to the appropriate parties.
    • Review individual clinical records for presence of adequate and required documentation, using chart review tools.
    • Participate in relevant internal and external training.
    • Participate in Population Health team meetings, as assigned.
    • Participate in supervision, as assigned.
    • Perform other related duties as assigned.
    WHAT WE LOOK FOR
    • High School diploma or its satisfactory equivalent.
    • Minimum of two (2) years of employment experience, healthcare and/or care management related experience preferred.
    • Bilingual Spanish preferred.
    • Ability to work collaboratively and in a fast-paced environment.
    • Excellent communication and problem-solving skills.
    • Respect for the rights of individuals to make their own decisions about family planning, etc.
    • Ability to communicate easily and display a cordial manner towards individuals from a variety of socio-economic, cultural, and religious backgrounds.
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