population health - Lewes, United States - Beebe Healthcare

Description

Why Beebe?:

Become part of the Beebe team - an inclusive team positioned in a vibrant, coastal community. Enjoy a fulfilling career as you support the health of our patients and a team focused on excellence.

In addition to competitive compensation and wellness benefits (medical, dental, vision, and prescription) Beebe Healthcare also offers:

• Sign-on and Referral Bonuses for select positions
• Tuition Assistance up to $5,000
• Paid Time Off
• Long Term Sick accrual
• Employer Contribution Plan
• Free Short and Long-Term Disability for Full Time employees
• Zero copay for drugs on prescription plan for certain conditions
• College Bound 529 Savings Plan
• Life Insurance
• Beebe Pers via WorkAdvantage
• Employee Assistance Program
• Pet Insurance

This is a grant-funded, term-limited position through June 2025

This role is a frontline population health worker who is also a trusted member of the community and/or has a close understanding of the community served. This trusting relationship enables the Community Health Worker to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competency of service delivery.

The Community Health Worker (CHW) is responsible for assisting patients and their families to navigate and access healthcare, community services, other resources, and adopt healthy behaviors. The Community Health Worker will be expected to build and maintain relationships with patients, including reaching out to them on a regular basis via telephone, at our clinic sites including our mobile health clinic locations, at the participants' homes or agreed-upon places in the community. This will occur during specific follow-up visits and on an as-needed basis. They will be provided with appropriate training and oversight. The CHW may also support providers and Care Coordinators through an integrated approach to care management and community outreach. Activities will promote, maintain, and improve the health of patients and their families. The Community Health Worker (CHW) behaves in a professional manner and consistently demonstrates and promotes the values of respect, exceptional service, continuous improvement, safety, trust, and transparency for the patient and all members of the healthcare team. The CHW is committed to the constant pursuit of excellence in improving the health status of the community. We are looking for CHWs who are patient-centered, flexible, and organized. Specific Duties & Responsibilities: Assessing for social needs through a standardized social barrier assessment tool Linking participants with community resources to address health-related social needs. Linking participants to existing clinical and administrative services. Assesses functional and social needs of members and collaborates to develop and implement solutions with the frequency established in the model of care Establish goals and a plan of care to meet identified functional and social needs Begin implementation of care plan Work collaboratively with the multidisciplinary team to engage resources and strategies to address medical, functional, and social barriers to care Works closely with clinicians and colleagues to help bridge the gap for these previously un-engaged patients and patients with whom contact was lost Identify, refer, and coordinate available community resources to address non-medical needs and ensure patient access to services Responsible for registration and scheduling of patients in appropriate EMR Completely and accurately document in patient's electronic medical record (EMR), currently Athena and/or Cerner Document interactions with patients including information needed for follow up purposes Provide patients and family members with education regarding the need for follow up as appropriate during each patient visit Actively participate in organizational quality initiatives Participate in collaborative multidisciplinary team meetings to optimize clinical integration, efficiency, and effectiveness of care delivery (e.g. Microsoft Teams virtual meetings) Demonstrate a commitment to the mission, vision and strategic goals of Beebe Healthcare and its healthcare delivery including the ability to integrate values of compassion, integrity, performance.

• Ability to travel up to 50% of the time for field-based work Schedule is Monday - Friday, 8:30am to 5:00pm with possibility of need-based flexibility
• Required to have a dedicated work area established that is separated from other living areas and provides information privacy
• Ability to keep all company sensitive documents secure (if applicable)
• Demonstrates sensitivity and empathy in dealing with patients and families under stress.
• Uses knowledge and judgment in assisting patient and families in problem solving.
• Utilizes decision making skills in evaluating alternatives and determining best plan of action.
• Works under pressure of time and shifting priorities.
• Ability and willingness to self-motivate, prioritize, and be willing to change processes to improve effectiveness and efficiency.
• Adapts to changing patient and/or organizational priorities.
• Excellent organizational skills. Knowledgeable of local community resources.
• Previous experience as a CHW and knowledge of community resources highly desirable.
• Soft Skills: Knowledge of culture and values of communities served Familiarity with the resources available in Sussex County Ability to work with diverse care teams
• Exhibit independent professional judgement within boundaries of role, but the ability to consult and engage with other team members for improved patient outcomes
• Valid Delaware driver's license and access to an insured automobile that lists employees on the insurance policy. Ability to drive to and from a variety of settings in varying weather conditions.
• Familiarity with Microsoft Office applications (i.e., Word, Excel, Outlook).
• Ability to deal with frequent changes, delays, and/or unexpected events.
• Ability to establish positive, supportive, and trusting relationships with and among patients, their family members, and colleagues.
• Ability to work collaboratively and effectively within a team.
• Ability to take the initiative, problem-solve, and make decisions.
• Having empathy and compassion for those struggling with their health and issues in their lives.
• Strong oral and written communication skills in English. Strong oral and written communication in Spanish is preferred but not required. Strong organizational and effective time management skills.
• Willingness to advocate for patients in the healthcare setting.
• Willingness to learn new things (such as new computer programs, i.e., Unite Delaware; or new skills).
• Preferred Qualifications: 3+ years of experience in working with at risk populations
• 2+ years residing within Sussex County
• Previous experience as a CHW and knowledge of community resources highly desirable.
• CHW Certification 1+ years of knowledge of Medicare/Medicaid population
• Field based experience: Certified Nursing Assistant / Home Health Aide, or Medical Assistant
• Bilingual fluency in Spanish and English
• Experience working in managed care

• Clear Communication Skills Both Written And Verbal
• Able To Keep Confidential Information Regarding Patients, Team Members
• Able To Withstand Crisis Situations
• Has Skills To Provides Customer Service To Patients, Team Members And Visitors
• Knowledge And Experience With Electronic Health Records

High school graduate or equivalent