Description

SUMMARY:

As a Chronic Care Management (CCM) Community Health Worker (CHW), you will play a fundamental role in improving the health and well-being of individuals and families within the care management program. Working closely with patients, healthcare providers, and social services organizations, you will facilitate communication, provide navigation services, support, education, and resources to promote healthy behaviors and address health disparities. 

This position can be full or part time depending on the employee's needs.

MINIMUM QUALIFICATIONS:

· Prefer 2 years of experience in the fields of health, public health, or social services; an emphasis on community and population health and care coordination is desirable. Certification as a Community Health Worker is a plus.

· Fluency in English; bilingual English and Spanish preferred.

· Must have a valid driver's license.

· Excellent communications skills, both oral and written

*Bilingual English/Spanish preferred.

KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED:

· Knowledge of local healthcare resources, social services, and community organizations.

· Excellent communication and interpersonal skills to effectively engage with diverse individuals and groups. 

· Strong organizational and time management skills to handle multiple responsibilities and meet deadlines.

· Proficiency in data collection and basic computer skills for documentation and reporting purposes.

· Understanding of health education principles and the ability to effectively communicate health-related information.

DESCRIPTION OF DUTIES:

· Participate in the delivery of team-based care in assigned clinic(s).

· Utilize registries, electronic reports, and/or community referrals to proactively assess and coordinate services needed for community members. Assure that care is patient centered.

· Use clinical evidenced-based care guidelines to monitor patient health status and need for services by coordinating high-risk patient risk reduction, hospital and ER utilization, and improvement of patient outcomes.

· Use IRIS and Idaho Health Data Exchange to track immunization status and recall for immunizations.

· Collaborate with team members for appropriate tracking.

· Follow up with referrals and aids in scheduling appointments. 

· Follow up with patients as requested by provider.

· Assess patients’ readiness to change, monitor compliance with plan of care, and problem-solve barriers related to the health care system, and financial and psychosocial barriers. 

· Utilize behavioral strategies to help patients adopt health behaviors, improve self-care, and manage chronic disease.

· Make reminder calls for patient visits, to include but not limited to the guidelines set forth by FHS for PCMH and MU. 

· Assist Outreach and Enrollment staff with patient’s eligibility requirements for Medicaid, SSI, etc. and with coordination of enrollment with service agencies.

· Review Medicare, Medicaid, & other Payer reports and coordinates care with patients accordingly. Notifies schedulers of Medicare annual wellness visits needed.

· Conduct individual health education sessions, delivering information on preventive care, disease management, nutrition, exercise, and other health-related topics.

· Assist community members in accessing health related services, including scheduling appointments, coordinating transportation, and navigating community resources, insurance, or financial assistance programs.

· Serve as an advocate for the patients, helping them navigate the healthcare system, addressing barriers to care, and promoting policies that improve health equity.

· Participate in ongoing training, learning sessions, conference calls, webinars and other professional development opportunities as allowed. 

· Document and maintain records of encounters with individuals and/or families.

· Meet regularly with supervisor to review activities, identify problems, and identify priorities.

· Respect and appreciate the diversity of the community, adapting your approaches to effectively communicate and engage with individuals from diverse cultural backgrounds.

· Other duties as assigned.

OTHER RESPONSIBILITIES:

SAFETY:

Family Health Services enforces a safety culture whereby all employees have the responsibility for continuously developing and maintaining a safe working environment. Each employee is responsible for completing all training requirements, participating in emergency response tasks as requested, and serving on safety committees and teams as requested. In addition, employees must accept the responsibility for maintaining the safety of themselves and others by adhering to all written and verbal instructions, promptly reporting and/or correcting all hazards or unsafe conditions and providing feedback to supervisors and management on all safety issues.

COMPLIANCE (MEDICARE):

Family Health Services is committed to the very highest standards of ethics and integrity. It is our policy to properly determine the accuracy of reporting and billing our services in accordance with the rules, laws, and regulations of FHS, the state government, and the federal government. HS employees will do their part to ensure accurate documenting and billing practices, participate in compliance training and will identify and report any concerns or activities that may violate these standards.

Each employee will be trained on the FHS Medicare Compliance Plan and the Standards of Conduct and asked to sign a Conflict-of-Interest Statement at hire and annually thereafter. A copy of the Medicare Compliance Plan and the FHS Standards of Conduct are available on the FHS home page under the Compliance tab. 

PATIENT CENTERED MEDICAL HOME (PCMH):

Family Health Services is committed to providing our patients with the highest standards of care by becoming recognized as patient centered medical home. FHS staff are expected to participate in this process by being an active and willing PCMH (PATIENT CENTERED MEDICAL HOME) team member. Specific duties and expectations may vary and will be identified by position and site.

PROCEDURE COMPLIANCE:

Employees must read and understand the general and specific operational, safety, and environmental requirements of all plans, procedures, and policies pertaining to this job. 

WORKING CONDITIONS:

Work is normally performed in a typical interior/office work environment. None to limited physical effort is required. No or limited exposure to physical risk.