The Community Health Worker works to ensure that patients receive comprehensive and coordinated care across various healthcare settings and specialties. They collaborate with healthcare providers, patients, and their families to develop and implement care plans, monitor patient progress, address barriers to care, and facilitate communication among members of the healthcare team. Care coordinators complete case management, outreach, referral management and education as well as providing linkages to state and federal benefit programs and benefit program application assistance.

QUALIFICATIONS & COMPETENCIES

• High School Diploma equivalent required. Associate’s or Bachelor’s degree in a human services or related field preferred.
• Bilingual skills preferred
• Preferred Minimum of 1-year experience in care coordination, community health, social service, or medical practice. (such as Community Health Worker, Medical Assistant, Licensed Practical Nurse (LPN), Patient Care Technician, Home Health Aide, or other clinical support staff member)
• Experience in working with payer(s) and specifically Medicaid policies and programs, and knowledge of child access programs.
• Strong communication and interpersonal skills, with the ability to build rapport and establish trusting relationships with families from diverse backgrounds.
• Empathy, compassion, and sensitivity to the emotional needs of families coping with a child’s illness or injury.
• Organizational skills and attention to detail, with the ability to manage multiple tasks and priorities in a fast-paced environment.
• Cultural competence and awareness of social justice issues, with a commitment to providing equitable and inclusive care.
• Knowledge of community resources and social service agencies, with the ability to effectively navigate and access these resources on behalf of families.
• Proficiency in Microsoft Office and electronic health record systems.
• Flexibility to work occasional evenings, weekends, and holidays as needed.
• Ability to work independently as well as collaboratively within a multidisciplinary team.

OTHER

• This job description is an overview or major duties, activities and responsibilities required for the role.
• This description is not intended to be a complete listing of all tasks required for the role.
• Responsibilities will change with the needs of the organization.

Patient education/coaching

• Work with patients to establish health improvement plans and set personalized goals and supports patients in achieving those goals.
• Employ behavior change facilitation skills such as motivational interviewing, to assess readiness, health goal setting short and/or long-term needs, engage patient’s plans for change following the established plan of care.
• Conduct home and telephone visits and provides coaching to patients/caregivers around their behavior changes to improve health status, reduce health risks and improve quality of life.
• Assist with identifying patients’ barriers to self-care and the additional services patients may need, such as home health care, caregiver support, referral to various entitlements and resources.
• Help patients by reinforcing use of existing self-management skills and promotes the development of new skills to enhance success. Empower patients with skills to provide enhanced interaction with their health care provider. Provide cultural and language adaptation as needed.
• Foster an environment of individual responsibility. Help patients take ownership of their health care by having patients set their own personal health goals.
• Teach coping skills.
• Assist patient with self-monitoring activities.
• Promote active participation by the patient in his/her health care by encouraging patient communication of self-monitoring results to the patient’s primary health care provider

ESSENTIAL FUNCTIONS:

• The Community Health Worker will participate in and support the interdisciplinary care team efforts in the prevention and control of chronic diseases by providing patients/caregivers with self-management education and support
• Identify and communicate barriers to achievement of disease self-management and facilitate their removal
• The Community Health Worker provides education and advocacy and evaluates patients’ eligibility for social service programs.
• The Community Health Workers alerts members of the care team when follow-up is required and ensures efficient and successful access and linkage to the full array of physical and behavioral health services
• Assist and conduct various research projects in accordance with the organization’s needs and mission
  Responsibilities:

Relationship building

• Develop an effective and efficient interpersonal and trusting relationship with patients/caregivers while maintaining a supportive coaching environment.
• Provide education and social support to patients and their family members.
• Provide emotional support by showing interest and compassion. Report to professional team members any concern in order to ensure care plan revision as appropriate.
• Provide continuity and promotes trust. Act as patient advocate responding to and working to resolve patient concerns or barriers.

Establish linkages with services

• Reinforce and review the plan of care with the patient
• Call patients at intervals as per established plan of care to check on their progress, including making sure they have kept any scheduled medical or other appointments
• Assist patients with applications for public aid, payer specific programs, accessing medication, disability benefits, and other non-clinical issues as needed; assistance provided in person,, virtually, and by phone

Patient education/coaching

• Work with patients to establish health improvement plans and set personalized goals and supports patients in achieving those goals.
• Employ behavior change facilitation skills such as motivational interviewing, to assess readiness, health goal setting short and/or long-term needs, engage patient’s plans for change following the established plan of care.
• Conduct home and telephone visits and provides coaching to patients/caregivers around their behavior changes to improve health status, reduce health risks and improve quality of life.
• Assist with identifying patients’ barriers to self-care and the additional services patients may need, such as home health care, caregiver support, referral to various entitlements and resources.
• Help patients by reinforcing use of existing self-management skills and promotes the development of new skills to enhance success. Empower patients with skills to provide enhanced interaction with their health care provider. Provide cultural and language adaptation as needed.
• Foster an environment of individual responsibility. Help patients take ownership of their health care by having patients set their own personal health goals.
• Teach coping skills.
• Assist patient with self-monitoring activities.
• Promote active participation by the patient in his/her health care by encouraging patient communication of self-monitoring results to the patient’s primary health care provider.

Organizational duties:

• Maintain accurate patient records by documenting all contacts (successful and attempts),, services provided, and outcomes in order to track all clients and services for future reference.
• Track client information, schedules, files, and forms in a HIPAA compliant manner.
• Participates in program’s performance improvement activities. Provides suggestions for improvements and enhancements to the Community Health Worker program and interventions based on data/experience.
• Community canvassing and building strong partnerships
• Conducting social risk assessments, and developing tools for data collection and evaluation
• Documents interactions and interventions as directed.
• Performs other related duties incidental to the work described herein.

Patient Assessment

• Support the preliminary plan of care with the patient
• Understand patient and family’s goals, behavioral motivation, and readiness
• Identify needed services
• Screen clients for eligibility for direct and support services
• Obtain input and sign-off from the Care Coordinator
• Update plan of care as needed.
• Depending on the level of need identified in the assessment, the Community Health Worker will need to do more than provide information, their role is to coordinate the referral (call the provider, make the appointment on behalf of the patient, and ensure the patient gets to their appointment)

The physical demands described herein 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.

• Work for this job is performed mostly in office settings. Some outdoor work may be required.
• This is largely a sedentary role; some filing is required. This would require the ability to lift files, open filing cabinets and bend or stand as necessary.
• This position may require standing or walking for extensive periods of time for major events

The work environment characteristics described herein 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.

• This job operates in an office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.
• The office for this job is located in the same facility where RMH-NY provides temporary accommodations to pediatric patients and their families while the patients are undergoing active medical treatment at area hospitals. For some RMH-NY guests, medical treatment may include radiation therapy. While radiation therapy is never administered at RMH-NY, there is the potential for some radioactive material to be present in guests who have undergone radiation therapy. Based on radiation measurements performed throughout RMH-NY, it is not expected that individuals working at RMH will receive radiation doses that would exceed the general public limit (100 millirem per year).
• The noise level in the work environment is moderate to loud. Noise levels often increase with families and children who have temporary residence in the building as well as guests and musical performers for special events.
• This position requires flexible schedule at times to meet the needs of the families. Some weekends and evening hours are necessary