Create connections between vulnerable populations and the health care system

CHWs at RHG work to guide patients toward more permanent primary care services outside the hospital system. Establishing a secure, trusted connection with a primary care provider that can help prevent poor health outcomes and reliance on Emergency Departments to meet primary care needs.

Care coordination and care transitions for clients

The mobility of CHWs within their communities creates opportunities for more coordinated care. CHWs can serve as a liaison between multiple services and help with care coordination and care transitions for their clients. In the process of connecting clients with multiple services, CHWs build relationships with local agencies, advocating for their clients in the process. The more CHWs are involved in the community at large, the more effective the linkages between the community and the health care system become.^[v]

Assist clients with enrollment in programs and benefits for which they are eligible

In addition to connecting clients with health care services, CHWs work to connect clients with various social service programs for which they may be eligible. These programs and benefits can range from enrollment into SSI/SSDI to enrollment into a GED program.

Encourage cultural competence among health care professionals serving vulnerable populations

CHWs’ will build rapport with patients and families while also informing policies, procedures, and practices within the RHG clinic. CHWs have a unique insight into the perspectives of their clients which helps them identify barriers or unmet needs within the RHG clinic that may go unnoticed by clinicians or administrators.

Advocate for vulnerable populations within the health care system and the community at largeCHWs will amplify the voices of the community within their RHG clinics thereby informing health professionals of the evolving needs and conditions of their target population.Successful candidate must demonstrate the Rural Health Group Core Competencies, which include:

1. Good Judgment
2. Communication/Customer Service/Teamwork
3. Passion
4. Honesty
5. Responsibility
6. Job-Specific Skill Set

 Key Responsibilities -

• Work closely with patients to reduce hospital stays, ED admissions
• Work with providers, office team and insurance plans to improve quality measures
• Promote healthcare outside 4 walls of office visits

Other Job Duties/Responsibilities

• Convey the purposes and services of a program to the user population and the impact that program or service would have
• Help patients develop health management plans and goals
• Follow-up with health management/care plans with both patients and providers
• Coach patients in effective management of their chronic health conditions and self-care
•  Assist patient in understanding care plans and instructions
•  Document activities, service plans, and results in an effective manner while strictly adhering to the policies and procedures in place
• Work collaboratively and effectively within a team
• Establish positive, supportive relationships with participants and provide feedback
• Help clients in utilizing resources, including scheduling appointments, and assisting with completion of applications for programs for which they may be eligible
• Assist clients in accessing health related services, including but not limited to: obtaining a medical home, providing instruction on appropriate use of the medical home, overcoming barriers to obtaining needed medical care and social services
• Facilitate communication and coordinate services between providers
• Motivate patients to be active, engaged participants in their health
• Effectively work with people (staff, clients, doctors, agencies, etc) from diverse backgrounds in reducing cultural and socio-economic barriers between clients and institutions
• Build and maintain positive working relationships with the clients, providers, nurse case managers, agency representatives, supervisors and office staff
• Continuously expand knowledge and understanding of community resources, services and programs provided; human relations and the procedures used in dealing with the public as part of a service or program; volunteer resources and the practices associated with using volunteers, operations, functions, policies and procedures associated with the department or program area, procedures and resources available to handle new, unusual or different situations
• Identify and apply appropriate role definition and skilled boundaries
• Other duties as assigned

Requirements

• Associates Degree or higher
• Any combination of three years health/social services experience and/or education
• Medical experience and/or certification in Medical Assisting strongly preferred
• Bilingual/bicultural (Spanish) encouraged to apply
• Must be willing to obtain CHW certification
• Must have a valid NC Driver’s License and proper liability insurance
• Verifiable good driving record and reliable transportation; must be willing to travel
• Demonstrated cultural sensitivity and commitment to advocacy for cultural diversity
• Some experience working with vulnerable populations.
• Excellent organizational, telephone and communication skills
• Excellent leadership and teamwork skills
• Must be able to work independently as well as with a group 
• Ability to multi-task and work efficiently in a potentially stressful environment
• Ability to apply good judgment when carrying out responsibilities
• Pleasant, professional approach; must be able to work well with the public and provide excellent internal and external customer service
• Ability to establish and maintain positive, effective, professional relationships with patients, providers, coworkers, and superiors, state and local agencies, growers, and clients 
• Possess knowledge of modern office equipment and Microsoft Office software programs
• Basic computer skills; must be able to quickly learn to use eClinicalWorks electronic health record system to accurately complete the required documentation in patients’ records. 
• For bilingual candidates: Language assessment required before an offer of employment can be made
• All offers of employment are contingent upon passing post-offer, pre-hire drug screen and successful completion of background check (requiring social security number, date of birth, and driver's license number)