Job Abstract

If interested, please apply and send your resume to PBaker@mlkch.org

POSITION SUMMARY

The Community Health Worker Lead (CHW) reports to Population Health Manager and Health Programs Supervisor and is responsible for delivering comprehensive and seamless services that bridge the gap and integrate clinical and self-management aspects of health care. The CHW Lead is an integral part of the inter-professional team and provides collaborative, comprehensive and patient-centered care, and education conducive to behavior change and improved quality of life. The CHW Lead supports and advocates for people affected by health disparities to optimize quality care. The CHW Lead promotes self-management to achieve individualized behavioral and treatment goals that reduce risks and optimize health outcomes.  The CHW Lead will provide social support, resources and community outreach activities to an underserved population of patients in the outpatient setting. Services will be provided to individuals that come from diverse cultural backgrounds, ensuring that underserved communities receive the proper resources.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• In collaboration with the Care Managers CHW completes comprehensive assessments for each patient including emotional and behavioral health, interprets personal health data, develops an individualized care plan based on the patient’ assessed needs and goals and promotes successful self-management.

• Comfortable in working with patients who are considered vulnerable, challenging to engage, or those who suffer from mental health and/or substance abuse concerns. 
• In collaboration with the Social Services Specialist/Social Worker and community agencies will provide education and resources to patients and/or their families driven by an individualized plan of care that is culturally appropriate.
• In collaboration and guidance of the Interdisciplinary Team, provide referrals and coordinates services to community agencies as appropriate with a warm hand-off.
• Serves a limited caseload of clients in a similar manner as Community Health Workers, taking on more complex cases as needed. Includes assisting clients in their homes, community, or clinic setting, documenting client encounters, maintaining client files and documenting activities. Educates clients, assists them in accessing health related and social services, provides support and advocacy and facilitates aces to community resources.
• Integrates skills and knowledge of self-management  into clinical practice.
• Advocates for and communicates about improved quality of care and outcomes for those living with, at risk for, and affected by chronic conditions.
• Documents all individual contacts/visits in the Electronic Health Record and outcomes data base according to the guidelines in a timely manner.
• Participates in meetings, serves on committees, and represents the department and hospital/facility in community outreach efforts as appropriate.
• Oversees all facets of the daily operations of the organizational unit, to include functional coordination and administration of subordinate staff performing related work.
• Provides lead direction to Community Health Workers, which include orienting, and training; assigning workload; planning, monitoring, and evaluating program results; coaching and counseling employees.
• Assists in the creation of training modules and continuing education curriculum for Community Health Workers.
• Conveys all questions and concerns of Community Health Workers regarding clients and plan of care to health care system payers.
• Manage accurate documentation in EMR system to ensure that program requirements are met, high-quality care is provided, and timely payment is received.
• Travels extensively to client homes, community locations, various agencies, and other outreach destinations.
• Gathers, enters and analyzes data on programs, creating relevant and usable reports on program data and metrics. Consolidates data and produces relevant, meaningful, timely reports.
• Identifies, builds, and maintains relationships with community partners, identifying opportunities for new community sites and community partners.
• Provides support to Program Manager, assisting with daily operations, managing staffing schedules, calendaring, and liaising with community partners, especially in regards to staffing community events and sites.
• Tracks deliverables for assigned program(s) on a regular basis, ensuring compliance with grant and departmental requirements.
• Participate in the evaluation of clinical care, utilization of resources, and development of new clinical tools, forms, and procedures.
• Other duties as assigned.

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A.   Education

• Bachelor’s degree in Social Work, Public Health, Psychology, Sociology, Human Services, or related degree required. Candidates with at least five (5) years of experience in a similar role will be considered in lieu of degree.  
• Community Health Worker Certification required.

B.  Qualifications/Experience

• Bilingual Spanish preferred.
• At least one (1) year of experience in Care Coordinator and/or Community Health work.
• Basic Life Support (BLS) Required.
• Knowledge of medical terminology preferred.
• Experience working in a multi-cultural community based setting for at least 1 year preferred
• Microsoft Office experience

C.   Special Skills/Knowledge

• Written and verbal fluency in English required.
• Good communication skills and willingness to provide emotional support, encouragement and motivation to patients.

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