Community Health Worker

The Community Health Worker (CHW) will be an integral part of WVP Primary Centered Care Homes. They will work with the team that consists of primary care providers, Care management Coordinator, community partners, and patients/caregivers. CHW coordinate services and facilitate communication within the healthcare team. The CHW will be responsible for assisting high-risk, high-need patients/caregivers to navigate timely access to referrals and coordinate care. They will help the team to address opportunities to improve patient transitions of care, focusing on hospital and ED Discharges, as well as post-acute care facility usage, and interactions with specialists and linkages with community and social services.
Key Functions/Responsibilities

• Responsible for establishing trusting relationships with patient/caregiver and connect those patients to care, eliminating barriers and advocating for systemic changes.
• Ability to gain access to hard to reach individuals and to patiently coach and support them as they work toward health goals.
• Assist and engage patients/caregiver with care planning and goal setting.
• Create connections between patients and the health care system.
• Serve as a liaison between multiple services and help with care coordination and care transitions for patients.
• Build relationships with local agencies by advocating for patient in the process.
• Assist patients with enrollment in various social service programs and benefits for which they are eligible.
• Provides current and appropriate general health and wellness education throughout the interaction with patients.
• Help patients identify and document barriers or unmet needs in efforts to connect clients to health and social services.
• Provide ongoing follow-up and goal setting with patient/caregiver.
• Conduct visits when appropriate (Home, Hospital, Facility, Clinics).
• Provides Non-Emergency Medical Transportation (NEMT) to necessary health and social services appointments
• Identify the nature and complexity of social needs in care plan. Access, view, track and complete Electronic Health Information with accuracy and in a timely manner.
• Work cooperatively with care team members that are assigned to the same patient to help ensure that the patient has comprehensive and coordinated care.
• Coordinate patient care with providers, and agencies through phone calls, emails, fax and text. Requires computer proficiency and ability to multitask.
• Record patient care management information in the EMR (Electronic Medical Record) and other software no later than 24 hours after patient contact.
• Attend Care Team Meetings and, trainings as requested
• Manage assigned caseload of patients.
• Possess strong organization skills, self-motivation and be able to work both independently and as a part of a team.
• Have basic knowledge of the healthcare system and medical terminology.
• Bi-lingual English/Spanish preferred.
• Certification of successful completion of a Community Health Worker formal training program.
• 2-3 experience preferred.
• Experience working in a multi-cultural setting.
• Demonstrate strong interpersonal skills while maintaining healthy professional boundaries, retaining objectivity, and preserving confidentiality in accordance with HIPAA guidelines and WVP policy.
• Valid Oregon Driver’s License; travel to meet with families, providers, medical management, case management, vendors, and community partners.
• FSC position requires driving, sitting at a computer screen, and standing for extended periods of time. Duties may include frequent walking, bending, stooping and repetitive tasks. Position requires lifting of loads of 25lbs or greater with or without assistance

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