General Responsibilities: The Community Health Worker is a member of the Community Health Team (CHT); a multi-disciplinary team comprised of Nurse Care Managers, Community Health Workers, Care Management Outreach Workers and Behavioral Health Clinicians. The CHT supports patients of Thundermist Health Center who are dealing with complex medical and behavioral health and/or substance issues and require a more intensive home and community-based intervention. Community Health Workers play a critical role in the Community Health Team by providing care coordination, peer support, community resources and referrals. Community Health Workers visit patients in their homes and in the communities in which they live while providing culturally sensitive approaches to help patients achieve their health goals, Provide case management services, financial resources counseling, crisis intervention, supportive counseling. Support and advocate for patients to reduce barriers to health care. Coordinate clinical care as it relates to social services for assigned patients in the Ryan White Part C program, or other programs as assigned. Supervisory Responsibilities: None Qualifications: To perform this job successfully, an individual must be able to perform each essential duty in a satisfactory manner. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Education and Experience: High School diploma and a combination of education and skills to effectively carry out responsibilities and assignments, such as previous experience working in a community-based setting. Ability to work independently and effectively in a team environment; collaborate with other CHT staff. BLS Certification. Computer skills-MS Office, (Excel, PowerPoint), Electronic Health Records Courteous and cooperative attitude, Excellent written and oral communication skills Experience with Diverse/High-Risk Populations-Infectious Disease Preferred Highly organized and strong interpersonal skills. Maintain timely and accurate records and documentation as required. Valid driver’s license and reliable transportation with proof of RI minimum requirements of auto insurance (including a 100/300 K Rider) to utilize your automobile for work purposes. Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Ability to tolerate moderate to high levels of stress. Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Conversing in multiple languages Coordinating several tasks simultaneously Meet with patients in the community; at their home, in the hospital, or other community settings. Flexibility to travel within Rhode Island to meet the needs of the patient. May require climbing several flights of stairs Hybrid position- Multisite Support-will complete job duties and functions on site as required. Work Schedule Demands: Full time, 40 hours per week. As scheduled. Some evenings required. May require flexibility when necessary for patient crisis. On call rotation as needed. Language & Communication Skills: Bilingual ability preferred. Cultural sensitivity necessary to work with a diverse patient and staff population. Requires excellent oral and written communication skills at all levels of client arm staff interaction. Documents clearly and concisely all interactions in the medical and social service record. Must be able to communicate as a part of the clinical team Confidentiality of Information: Requires sound communication skills at all levels of client/staff interaction. Documents clearly and concisely all client interactions in the medical records. Must be able to converse in appropriate medical terminology. A high level of confidentiality. Must always maintain all policies of confidentiality surrounding agency and patient information. Confidentiality and adherence to HIPPA requirements must be always maintained with patient information and quality information. Frequent access to computer information system and patient information. Access to confidential information through patient charts and financial information. Significant Job Functions: Accompanying patients during doctor’s appointments, assisting with food access needs, picking up prescriptions at the pharmacy, completing forms for benefit applications, and assist with other tasks as needed that support their medical and behavioral health care needs. Transportation of patients may also be required if patient does not have access to any other form of transportation, or if it is a critical appointment that requires staff transport. Assist in the development of a patient Care Plan to include actions designed to improve the patient’s health status. Remove the barriers that are preventing them from getting high quality and timely access to PCP and specialist care. Build trusting relationships, serve as an advocate, and peer mentor with the goal of empowering the patient to become more independent and self-sufficient. Conduct health assessments. Educate patients on appropriate Urgent Visit and ER use. Key member of multi-disciplinary Community Health Team; collaborates with physicians, other care team members (Medical Assistants, Nurses, etc.), hospitals, partner agencies, members of the CHT in the patient’s network of care to improve patient care; Obtain progress notes from outside providers involved in patient care. Meet with patients in the community, at their home, in the hospital, or other community settings. Perform other duties are required. Utilize Motivational Interviewing skills and other patient engagement techniques with patients and caregivers. Program Specific Duties and Responsibilities: Ryan White Part C Assist Patients with Health Insurance applications and/or RIFAB Enrollment Attend applicable trainings, HIV Case Management Certification, HAB You Heard Webinar Series or other trainings as applicable Attend Ryan White Part C Program Clinical Meetings Complete Annual Health Education & Risk Assessments for Part C recipients. Coordinate with AIDS Service Organizations regarding Medical Evaluation Forms Facilitate patient Ryan White Part C Patient Eligibility for the Part C program. Lead annual Ryan White Patient Focus Groups Program Specific Duties and Responsibilities (Continued): Provide assistance for patients who require HIV Medication Co-Pay Cards Provide Ryan White Part C Patient Case Management services to identified patients who require such level of care Serve as the point of contact for Part C patients who are recipients of the RI AIDS Drug Assistance Program (ADAP). Complete enrollments, recertification and coordinate with RI EOHHS The above listing of duties is not meant to be all-inclusive. Employees may be asked to perform other project-based duties and tasks as assigned by management based on the needs of the organization.