Description

The Pediatric Community Health Worker (CHW) facilitates population health and care coordination in an FQHC setting. This role collaborates with primary care and behavioral health and serves as a central link to an identified population of our patients. Through skilled assessment, education, collaboration and coordination of health care and community resources, the CHW supports patients and their families in enhancing their self-efficacy/management skills, achieving optimum functional health status, and their best quality of life. The Pediatric CHW develops effective partnerships with patients/families, staff and systems to create an environment of high quality, evidence-based, cost effective care and patient focused outcomes.

Requirements

Minimum qualifications:

High School Diploma or equivalent, 1-2 years working in community health experience working. FQHC experience and Community Health Worker Certificate preferred . Complete Heritage Health financed CHW Core Training certificate program within 6 months of hire.

Knowledge, Skills, and Abilities Required:

· Able to organize, prioritize and coordinate multiple activities and tasks. 

· Ability to establish and maintain effective working relations with organization leaders and staff. Strong customer service, patient advocacy, and team orientation philosophy of care. 

· Systems thinker with good analytic and problem-solving skills. 

· Self-starter with ability to work independently and use sound judgment. 

· Strong computer skills with experience in working with electronic data and reporting systems. 

Duties and Responsibilities:

· Responsible for establishing trusting relationships with patients and their families while providing general support and 

encouragement.

· Provide ongoing follow-up, basic motivational interviewing and goal setting with patients/families. 

· Follow – up with patients via phone calls, home visits and visits to other settings where patients can be found. 

· Help patients set personal health related goals and attend appointments. 

· Provide referrals for services to community agencies as appropriate. 

· Help patients connect with transportation resources and provide appointment reminders in special circumstances. 

· Exhibit excellent working relations with patients, visitors and staff, 

· Effectively communicating HH’s mission. 

· Work closely with medical providers to help ensure that patients have comprehensive and coordinated care plans. 

· Work collaboratively with other clinical personnel assigned to the same patient. 

· Knowledgeable about community resources appropriate to needs of patients/families.

· Responsible for providing consistent communication to the Case Manager to evaluate patient/family status, ensuring that 

provided information, and reports clearly describe progress.

· Act as a patient advocate and liaison between the patient/family and community service agencies. 

· Record patient care plan information in the EMR and other software no later than 24 hours after patient contact. 

· Attend regular staff meetings, trainings and other meetings, as requested. 

· Manage assigned caseload of patients

· Facilitates population health management in educating the patient/family on the proper use of the Emergency Room, and

provides information for alternatives. 

· Coaches patients in effective management of their chronic health conditions and self-care. Assists patient/family in 

understanding care plans and instructions. 

· Motivates patients/clients to be active and engaged participants in their health and overall well-being.