Organizes and facilitates care activities and promotes self-management by advocating for, empowering, and educating the patient. Must deliver healthcare-related services that are of quality, efficient and cost-effective, and in a professional manner.

Essential Duties and Responsibilities include the following. Other duties may be assigned:

• Assist individuals and communities to adopt healthy behaviors.
• Conduct outreach to implement programs in the community that promote, maintain, and improve individual and community health.
• Responsible for building and maintaining an active patient caseload necessary to meet productivity requirements.
• Assist in developing processes and procedures related to CHW roles and translate materials.
• Participate in new program initiatives related to CHW roles, and advocate for patients and community health needs to ensure the appropriateness of initiatives.
• Conduct patient outreach and engagement activities patients, including face-to-face, mail, electronic, and telephone contact.
• Conduct outreach and engagement activities that support patient continuity of care, including re-engaging patients in care if they miss appointments and/or do not follow up on treatment.
• Assist patients in completing patient consent and other clinic or program-related forms.
• Conduct initial and periodic needs assessments using tools to collect social determinants of health data, including assessing barriers and assets (e.g., transportation, community barriers, social supports); patient preferences; and language, literacy, and cultural preferences.
• Support the development and execution of patient care plans, including assisting patients in understanding care plans and instructions and tailoring communications to appropriate health literacy levels.
• Conduct home visits and accompany patients to clinic visits per protocol or as determined in consultation with the supervisor.
• Promote patient treatment adherence through assessing patient readiness to make changes; assisting patients in making changes to daily routines; identifying barriers; and assisting patients with developing strategies to address barriers.
• Provide social support and informal counseling, behavioral change support, and assistance with goal setting and action planning.
• Assist patients with navigating health care and social service systems, including arranging for transportation and scheduling and accompanying patients to appointments as determined in consultation with the supervisor.
• Assist care managers in monitoring and evaluating patients’ needs, including for prevention, wellness, medical, specialist, and behavioral health treatment; care transitions; and social and community service needs.
• Identify available community-based resources, and actively manage appropriate referrals, access, engagement, follow-up, and coordination of services to patient supports and resources, including resources related to housing; prevention of mental illness and substance use disorders; smoking cessation; diabetes; asthma; hypertension; self-help/recovery resources; and other services based on individual needs and preferences.
• Document all efforts to address SDOH issues in electronic medical records.
• Provide support and education for chronic disease self-management to patients and their families.
• Coordinate access to the basic determinants of health (e.g., food, clothing, shelter, income, utilities).
• Use health information technology to link to services and resources and communicate among team members, providers, patients, and their families/caregivers.
• Provide information on patients to the healthcare team as appropriate for a greater understanding of the patient.
• Electronically document activities and patient information and interventions in patients’ electronic health records.
• Participate in events and projects with collaborating agencies to exchange information and remain current with developments in the field.
• Promote and educate patients on patient portal access and other CHASS electronic applications.
• Collect and report on data for program evaluation and assist in the analysis and dissemination of research findings.
• Manually and/or electronically document activities and patient information and interventions in patient-tracking systems, care management software programs, and other program systems.
• Will be assigned to different CHASS facilities on a rotational basis.
• Other duties as assigned.

Special requirements, qualifications, Licenses, or certifications:

• Experience working as a Community Health Worker with a target population.
• Must be fully bilingual in Spanish and English.
• Requires to travel between CHASS Facilities as needed.
• The position requires independent travel to participant homes, and working evenings and weekends as needed to accommodate patient needs and preferences.
• Must have a valid Michigan driver’s license and access to an insured automobile that lists the employee on the insurance policy.
• Minimum of high school diploma or GED.