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Title: Community Health Worker
Company: Oak Street Health

ROLE DESCRIPTION:

The purpose of a Community Health Worker (CHW) at Oak Street Health is to act as the bridge between our patients, community, and medical systems in order to remove barriers and increase wellness across all life domains. A CHW is a patient’s advocate or liaison, accompanying patients through proactive in-person and phone outreach based on their care needs to promote health literacy and increase access to resources needed to live healthier lives. High levels of flexibility, problem solving, strong communication, and an intimate knowledge of the community served are required to be successful.
CHWs work closely with Medical Social Workers to manage patient care plans, support care team decision making, and coordinate clinical and complementary services needed to provide high quality health care and improve the quality and cultural competence of service delivery. CHWs are expected to work within their scope of practice. There is no expected clinical license for this position.

CORE RESPONSIBILITIES:

• Establish and maintain strong interpersonal relationships with patients, community organizations, team members, and partners to coordinate patient needs
• Manage patient referrals defined by the care team & collaborate with the Medical Social Worker on action plan
• Facilitate communication between all identified parties involved in patients’ care as needed (e.g., family members, caregivers, medical providers, community-based organizations)
• Form relationships with and build an inventory of local community organizations that may benefit our patients
• Connect patients to state and local community resources related to housing, transportation, food, and activities of daily living among other social and physical barriers to health.
• Assist patients with completion of applications for accessing eligible benefits and resources
• Promote goal setting and achievement to improve patients’ quality of life and self efficacy with patients. Goal definitions are agreed upon by the care team
• Meet with patients in patient-centered and patient-preferred locations (e.g., Oak Street Health center, patient’s home, external medical provider facility, community setting)
• Community Health Workers should plan to spend about half of their time outside of the center in patient-centered locations; this means having access to a reliable means of transportation to do so is required
• Drive engagement with high risk individuals (e.g., completed specialty appointments, adherence to Post Discharge Visits) may include accompaniment to appointments
• Complete referrals to organizations and agencies as needed
• Deliver culturally appropriate health education in the areas where OSH has provided competency training to the CHW
• Support care team decision making through participation in interdisciplinary team meetings
• Document interactions with patients in electronic medical record in a timely manner while maintaining HIPAA standards and confidentiality of protected health information
• Manage time, set priorities, work independently, and collaborate effectively with an interdisciplinary medical team
• Other duties as assigned