Description

At ConcertoCare, we are redefining care and aging for millions of US seniors and other adults with complex care needs by delivering human-first, tech-enabled care in the home. Our care teams leverage our value-based, interdisciplinary care model to address unmet health and social needs and to improve quality of life for our patients. We take a holistic, equitable, and compassionate approach to health and wellness in partnership with our patients and their families, caregivers, and communities. In short, we strive to offer the kind of healthcare that we would want our own loved ones to experience.

The ConcertoCare Community Health Worker serves as a key member of a multidisciplinary care team in an integrated care setting, addressing the needs of our most medically and socially complex patients. Our care teams work in concert to bring close attention to patient’s social determinant of health needs and maintain an intense focus on engaging patients and caregivers in their care.

Community Health Workers:

• Employ health coaching techniques to lead on patient engagement, patient education and coaching, as well access to and care navigation of systems targeted at improving health outcomes.
• Are a critical component of the care teams work to ensure patients meet their care plan goals, reduce unnecessary utilization of emergency departments and admission/readmission to inpatient units.
• Demonstrate deep cultural competency and leans into patients’ diverse beliefs, values, and social norms, and ensures care is provided in a manner that is culturally appropriate to meet the needs of all patients served.
• Seek opportunity to contribute to the health and wellbeing being of highly complex patients.
• Enjoy a collaborative multidisciplinary team-based approach to care and are excited to engage in developing and nurturing our innovative, value-based clinical model focused on caring for patients with complex and social support needs.

Responsibilities:

• Accept referrals from members of the care team and maintain a panel of patients to support the provision of basic needs impacting patients’ social determinants of health (housing, food, healthcare access, etc.).
• Ensure patient’s SDOH needs are met through effective assessment of needs, identification of appropriate resources, and ensuring patients are accessing available resources both internally and externally.
• Employ creative and adaptive strategies to support patients with health literacy needs while simultaneously coaching patients and caregivers to develop advocacy skills when engaging with systems of care.
• Perform home safety assessments to address barriers to patients remaining independent in their homes and other community residential settings.
• Demonstrate ability to engage patients in care by persistently forging trusting relationships through effective rapport building and use of evidenced-based practices such as Motivational Interviewing.
• Outreach to patients telephonically and in-person, and work diligently to maintain contact with patients experiencing transiency due to displacement, housing insecurity, mental illness, poor familial/social connections, and homelessness.
• Participate in and support the effective evaluation planning, development, and execution of patient care plan in collaboration with the patient’s assigned care manager, primary care provider, and the rest of the patient’s care team.
• Coach patients on problem solving, self-care, and self-management to close care gaps and to teach skills for health promotion and prevention.
• Partner with patients and caregivers to address barriers that get in the way of adopting healthier lifestyle (i.e., smoking cessation, weight loss, stress reduction).
• Use digital tools such as remote patient monitoring and web-based resource finder to assist patients in improving health outcomes, supporting patient access, learning and movement towards greater care management independence.
• Assist patients in accessing health related services through activities such as appointment scheduling, transportation coordination, and assistance with completing applications for resources.
• Follow-up on referrals telephonically and in-person when appropriate, and facilitate effective communication between patient, caregivers, internal and external providers, as well as community-based organizations.
• Document patient encounters, referral activities, and other pertinent information in electronic health record ensuring all encounter notes are locked within 72 hours of the encounter date.

Requirements

• High School Diploma or equivalent; will consider candidates with lived experience
• Experience working in an integrated, team-based care setting
• Experience working with adults/older adults preferred
• Experience in community outreach work with adults experiencing chronic conditions, mental illness, substance disorders, and/or biopsychosocial instability
• Strong ability to engage patients and build rapport
• Access to reliable transportation required
• Experience navigating healthcare systems is a plus
• Excellent team orientation and ability to foster collaborative relationships with others through both in-person and virtual platforms
• Excellent problem-solving, triage, and critical thinking skills
• Ability to manage patient complexity and multiple clients with diverse needs
• Ability to communicate effectively in writing and verbally.
• Demonstrate ability to perform multiple concurrent tasks with minimal supervision and meet deadlines.
• Knowledge of Medicare and Medicaid populations a plus.
• Proficient in computer skills to include Microsoft Office Suite (Outlook, Excel, PowerPoint, Word).
• Knowledge and ability to navigate internet-based tools and applications, and proficient in computer typing with a minimum typing speed of 40 WMP.
• Demonstrates high level of professionalism.

COVID-19 Vaccination Policy

Our COVID-19 Vaccination Policy is aligned with the CMS Omnibus COVID-19 Health Care Staff Vaccination Rule that mandates providers who work in Medicare and Medicaid certified facilities to be fully vaccinated to best care for our frail and elderly populations. Based on this CMS requirement, ConcertoCare requires all “frontline workers” to be fully vaccinated.

We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.

ConcertoCare is an Alcohol/Drug/Smoke-Free Workplace