Care Transitions Community Health Worker

US-CA-San Leandro
Job ID
2017-1153
SAN LEANDRO-ASH
Category
Family Support Services
Type
Regular Full-Time

Overview

The Patient Navigator works independently as a liaison between the Care Transitions Patient Navigator, Care Transitions Coordinator, TVHC and local hospital staff. With oversight from the Care Transitions Coordinator, the CHW identifies and assists the patient in accessing community resources and is the primary linkage to local Community Health Centers and programs. The CHW will employ effective interpersonal skills in order to coordinate the best outcomes for patients. A strong candidate possesses skills in systems navigation, to ensure patients return to their primary care setting while addressing social determinant related issues which create barriers to accessing ongoing health care. The Care Transitions CHW’s primary responsibility is patient engagement which happens on the phone, at a clinic or hospital setting and in patient’s home. Candidate must feel comfortable working with patients to address complex needs, patient advocacy, communicating with medical providers and data collection.   

 

Responsibilities

  • Advocate for all patients to help them achieve their best health
  • Serve as a liaison between hospital staff, clinic and community
  • Serve as a liaison between patients and PCP’s to help with culturally sensitive care and advocacy.   
  • Utilizes patient database (practice management and medical record system) for data entry and retrieval.
  • Conduct home visits with high need clients, 24-48 hours post-discharge, to maintain communication and assess the client’s living environment.
  • Assess the entitlement of community, transportation and ancillary services for clients.
  • Provides supportive counseling as needed and assess and make all appropriate outside referrals.
  • Maintain client information and case documentation in a confidential and professional manner.
  • Schedules, conducts and tracks patient assistance, follow-up and outcomes.
  • Coordinates linkage to various community resources, primary care providers and supports by scheduling appointments
  • and providing telephonic follow-up to ensure patients have received the care they need.
  • Maintains accurate records for reporting to various funding and inspecting agencies
  • Utilizes assigned EHR/EPM and assigned case management tools/database.

Qualifications

  • Knowledge of available health care and community resources appropriate for populations served, including but not limited to; pharmacy resources, shelters and housing resources, transportation resources, etc.
  • Knowledge of alternate levels of care including criteria required for payment and applications processes.
  • Able to meet case documentation requirement regarding content and timeliness.
  • Ability to report monthly on number of referrals, appointments made and links to community resources to designated team member.
  • Understands the importance of, and able to preserve, client confidentiality.
  • Cultural awareness and humility
  • Knowledge of data collection techniques and methods of analyzing and reporting data.
  • Excellent oral and written communication skills.  
  • Strong interpersonal skills and time management skills, ability to work effectively in a fast pace environment, with rapidly shifting priorities and competing demands.
  • Demonstrated organizational skills, excellent attention to detail and ability to provide timely follow up. Excellent task prioritization skills.
  • Ability to work independently with a minimum of direction.  Ability to exercise discretion and make independent judgments, seeking review when decisions represent significant departure from established guidelines.
  • Proficient to advanced PC skills, word processing, spreadsheets and data base programs.
    Must be available to work days and evening shifts
    Able to meet or exceed the Service Excellence Standards of TVHC, Inc.
  • Have valid California Drivers’ License, auto insurance, and accept travel assignments on the job as needed directed by the program.
  • Desire to work with an ethnically diverse population.

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