Clinical Community Health Worker - Transition of Care MA

COMMUNITY HEATH:

Community Health is a primary care network that provides nationally-recognized programs, a focus on wellness, dental, behavioral health and pediatric specialties, walk-in Express Care, a culture of community and quality health care that almost everyone, insured or uninsured, has come to depend on. As an equal opportunity employer, we offer a team-oriented, collaborative work environment for close to 400 employees at eight different locations in Rutland and southern Addison counties. 

ABOUT THE ROLE:

The Clinical Community Health Worker (CCHW) works collaboratively with the Transitional Care Manager to support care coordination and initiate timely outreach for patients recently discharged from inpatient settings or the emergency department (ED). The CCHW is responsible for assisting patients and their families in navigating and accessing community services, resources, and promoting healthy behaviors. Additionally, the CCHW will facilitate scheduling appointments with primary care providers across the organization. This role provides social support, informal counseling, and advocacy on behalf of individuals and the broader community health needs. Furthermore, the CCHW will implement procedures to address identified care gaps, as well as deliver personalized outreach and follow-up to patients.  

FUNCTIONS OF THE POSITION: 

• Care Coordination and Navigation: 
  • Collaborate with Transitional Care Manager to review in-patient and emergency department discharge lists daily. 
  • Schedule discharge follow-up appointments with respective primary care providers across the organization. 
  • Facilitate communication between patients and health care teams. 
  • Document outreach efforts in EMR and update Aledade App as appropriate. 
  • Create a working spreadsheet of all discharged patients to track and monitor progress. 

   

  Patient Education and Coaching: 

  • Provide education and encourage utilization of primary care versus avoidable ED visits. 
  • Provide ongoing follow-up and assist patients/families with meeting their established health and wellness goals.
  • Educate patients on the importance of routine follow-up and annual wellness visits. 

  
  

  Outreach and Advocacy: 

  • Perform timely outreach on patients identified through daily review process. 
  • Responsible for establishing trusting relationships with patients and their families while providing

  general support and encouragement.

  • Advocate for individuals to receive appropriate services.
  • Outreach patients to remind them of required testing and upcoming appointments based on designated protocols.

  
  

  SDOH Support: 

  • Screen for and assist patients with any SDOH needs (food insecurity, transportation, housing instability, financial barriers, etc.).
  • Connect patients to appropriate community-based resources and services, and assist with applications or referrals to social service programs as needed. 
  • Facilitate healthcare and social service system navigation.

  
  OTHER DUTIES:

  • Participate as an active member of the Transitional Care Team. Attend necessary meetings and receive guidance from the team on patient follow up.
  • Exhibit excellent working relationships with patients, visitors and staff.

  
  

SKILLS REQUIRED FOR SUCCESS:

• Medical Assistant
• At least one year experience in a primary care office preferred.
• Strong computer and organization skills.
• Ability to work independently, multitask, and respond to shifting priorities. 

 HOW WE SUPPORT YOU:

• Work Life Balance
• Generous Time Off
• Medical insurance and Dental insurance.
• Health savings account option.
• Robust 403 (b) retirement savings plan, with employer match and 100% vesting schedule.
• Comprehensive Wellness Program