Community Based Coordination Solutions seeks dynamic fulltime Community Health Workers (CHW) to join our New Mexico team. The CHW identifies barriers and helps coordinate care for an at-risk, complex patient population.
Position Available: Community Health Worker
Location: Albuquerque, NM
Reports To: Program Manager
Job Status: Exempt, Full‐time, Contract
Benefits: Health benefits; Connectivity Stipend; Travel stipend; 401K program
Salary: $26/hour to start
Position Summary

The CHW coordinates community and other resources to improve health care delivery for a complex patient population. The position includes significant field time with a variety of direct patient engagement duties including:

• conducting initial intake assessments and risk reduction interventions in person and over the telephone
• assistance/coordination with access to community resources
• assistance coordinating transportation and housing as needed
• engagement during crisis periods
• resource engagement and allocation
• regular meetings with clients’ care-teams

The CHW works as part of a team under the direction of a Program Manager. The position involves direct interaction with individuals deemed to be high utilizers of community resources to improve their overall care and help mitigate crisis events. The community health worker will be interacting with patients, primary care providers, medical specialists, social service entities and other community resources to provide an improved care plan for enrolled individuals. Enrolled individuals have typically been identified as “complex,” and most struggle with issues of homelessness, substance abuse and/or mental health.
Qualifications
This job requires the ability to demonstrate patience and understanding with this high medical and behavioral needs cohort, and the ability to navigate and assist clients with several challenging medical and social issues. While most duties will be conducted during pre-determined office hours, there will be requests for off-hours work.

We emphasize the following traits and requirements for this position:

• Desire and comfort working directly with at-risk individuals
• Lived experience with issues of homelessness, substance abuse, and/or mental health
• This position does require local travel, and a valid driver’s license is required; access to your own reliable transportation is preferred.
• Strong telephonic outreach skills, with a demonstrated ability to establish rapport over the phone
• Employees must be able to receive paychecks via direct deposit
• Basic computer access, intake and filing skills. Ability to access electronic information and participate in virtual meetings via tools such as Zoom.

Skills

Preferred skills for the position include, but are not limited to, the following:

• Patient engagement
• Performing intake assessments
• Maintaining frequent patient contact including reminders of appointments; assistance/encouragement to appointments
• Engaging individuals after each emergency department and/or primary care visit
• Assisting clients in finding resources (housing; transportation; food; care)
• Note – Many of the duties will be customized depending on the needs of each individual patient
• Ability to work directly with clients that may be suffering from any number of psycho-social issues including, but not limited to, mental health disorders, substance abuse issues, chronic medical conditions, and homelessness.
• Carry out work duties in a confidential and respectful manner, even when under stress.
• Care Plan creation and maintenance
• Engagement of local/regional Electronic Medical Records in a HIPAA compliant fashion
• Attending local community meetings as needed
• Engagement of community resources involved in patient’s care; this may include (but is not limited) to resources such as:
• Emergency Department personnel
• Primary Care Providers and Specialists
• Law Enforcement agents
• EMS personnel
• Behavioral Health Centers
• Substance Abuse Treatment Centers
• Therapeutic Courts
• Jails
• On-Call providers
• Housing Authorities
• Other community care coordinators and/or agencies

Positional Roles and Responsibilities

• Member enrollment into the program – this will typically involve phone and direct home and/or field-based contact with members during the enrollment process.
• Create care plans for every enrolled member.
• Assist members in a variety of activities in-home and community-based services, which may include assistance scheduling appointments, assist with travel to/from medical appointments, and engaging providers and community resources as needed.
• Problem-solve with members their barriers to care and establish with members their goals of care.
• Be available after hours (through a rotational call schedule) for emergent member needs.
• Work with team to create monthly client enrollment lists.
• Work with a variety of local resources, including (but not limited to) law enforcement, EMS, housing, medical, treatment, jail, shelters, and a variety of governmental agencies in development of ideal member enrollment plans. Participation in community multi-disciplinary teams as needed.
• Timely and accurate documentation of practices as per organizational policies and procedures

Organizational Roles and Relationships

• Adhere to organizational values and policies.
• Actively participate in organizational performance improvement activities
• Report directly to Program Manager
• Work in a team-based model of care
• Perform other duties on an as-needed basis
• Report to organizational leaders upon request
• Assist in submitting reporting data to organization as needed
• Protect client personal health information by compliance with HIPAA and additional relevant health-care IT related regulations.

CBC Solutions is an equal opportunity employer and will not tolerate discrimination based on race, color, religion, sex (including pregnancy, sex stereotyping, gender identity, gender expression or transgender status), national origin, sexual orientation, physical or mental disability, age, protected genetic information, status as a parent, marital status, political affiliation, or retaliation based on prior protected EEO activity.
Job Types: Full-time, Contract
Pay: $26.00 per hour
Expected hours: 40 per week

Benefits:

• Employee assistance program
• Health insurance
• Paid time off

People with a criminal record are encouraged to apply
Work Location: On the roa

The CHW coordinates community and other resources to improve health care delivery for a complex patient population. The position includes significant field time with a variety of direct patient engagement duties including:

• conducting initial intake assessments and risk reduction interventions in person and over the telephone
• assistance/coordination with access to community resources
• assistance coordinating transportation and housing as needed
• engagement during crisis periods
• resource engagement and allocation
• regular meetings with clients’ care-team

Positional Roles and Responsibilities

• Member enrollment into the program – this will typically involve phone and direct home and/or field-based contact with members during the enrollment process.
• Create care plans for every enrolled member.
• Assist members in a variety of activities in-home and community-based services, which may include assistance scheduling appointments, assist with travel to/from medical appointments, and engaging providers and community resources as needed.
• Problem-solve with members their barriers to care and establish with members their goals of care.
• Be available after hours (through a rotational call schedule) for emergent member needs.
• Work with team to create monthly client enrollment lists.
• Work with a variety of local resources, including (but not limited to) law enforcement, EMS, housing, medical, treatment, jail, shelters, and a variety of governmental agencies in development of ideal member enrollment plans. Participation in community multi-disciplinary teams as needed.
• Timely and accurate documentation of practices as per organizational policies and procedure

Organizational Roles and Relationships

• Adhere to organizational values and policies.
• Actively participate in organizational performance improvement activities
• Report directly to Program Manager
• Work in a team-based model of care
• Perform other duties on an as-needed basis
• Report to organizational leaders upon request
• Assist in submitting reporting data to organization as needed
• Protect client personal health information by compliance with HIPAA and additional relevant health-care IT related regulations