Duties andResponsibilities:

· Conveysthe purpose of the program to the patients and the impact that the service willhave on their medical care and outcomes.

· Helpspatients develop health management plans and goals through assessment tools toidentify individual patient needs.

· Follows-upwith health management plan and goals with both the patient and providers.

· Coachespatients in effective management of their chronic health conditions andself-care habits, such as preventing and managing uncontrolleddiabetes.

· Assistpatient in understanding plan of care, medications, self-management activitiesand instructions.

· Documentspatient vital signs, activities, plan of care and results in the electronicmedical record in an effective manner while strictly adhering to the policiesand procedures in place.

· Workscollaboratively and effectively within a team.

· Establishespositive, supportive relationships with participants and provide feedback.

· Helpspatients in utilizing resources, including scheduling appointments, andassisting with completion of applications for programs for which they may beeligible for to improve health outcomes.

· Assistsindividuals with self-management of chronic health conditions and medicationadherence

· Assistspatients in accessing health related services and overcoming barriers toobtaining needed medical care, social determinants of health and services.

· Facilitatescommunication and coordinate services between providers.

· Motivatespatients to be active, engaged participants in their health.

· Workseffectively with people (staff, clients, providers, agencies, etc.) fromdiverse backgrounds in reducing cultural and socio-economic barriers forpatients.

· Conductsintake assessments and educational and health maintenance sessions at theconvenience of the patient in the patient home, office, through telephone orother designated area.

· Buildsand maintains positive working relationships with the patients, providers,nurse case managers, agency representatives, supervisors and office staff.

· Continuouslyexpands knowledge and understanding of community resources, services andprograms provided in the community as well as within Tandem Health.

· Confersas needed and on a timely basis with health center providers regarding patientissues and concerns.

· Collects,reports, and enter data for purposes of evaluating CHW activities andcompleting grant reporting.

· Identifiespatients at risk for poor adherence.

· Communicateswith patients after a hospital discharge to follow up on treatment plans.

· Helpspatients connect with transportation resources.

· Actsas a patient advocate and liaison.

· Attendsregular staff meeting, trainings and other meetings as requested.

· Managesassigned caseload of patients.

· Otherduties as assigned.

Qualifications:

Educationand Experience:

· HighSchool Diploma or its equivalent required.

· Experienceworking as a medical assistant in a primary care setting preferred.

· Experienceworking in a community-based setting for at least 1-2 years preferred.

· Mustbe willing to seek Certification for Community Health Worker in accordance withthe South Carolina state-approved certification process.

· CurrentSouth Carolina driver's license required. Driving record must meet TandemHealth insurance standards upon employment, and continually thereafter.