C3 Community Health Worker - Care Management
Company: Community Health Connections
Posted on: June 6, 2021
As an integral member of the care management team the Community
Health Worker (CHW) will have the opportunity to make a profound
impact on the lives of people living with complex and/ or chronic
conditions, many of whom also face multiple barriers accessing care
and need support to succeed with achieving health care goals. This
position requires flexibility and may vary from day-to-day to meet
members where they are. Outreach methods may vary based on the
needs of the organization and may include telephonic or in person
in a variety of potential settings such as but not limited to, the
community, home, facility, or health center.
- Conducts initial outreach calls to encourage
member/representative and caregivers to participate in care
- Develop and implement outreach plans in collaboration with team
colleagues, based on individual, family, and community needs,
strengths and resources.
- Identify and share appropriate information, referrals, and
other resources to help individuals, families, groups and the
primary care team meet their needs.
- Gather and combine information from different sources to better
understand clients, their families and communities
- Initiate and sustain trusting relationships with individuals,
families, social networks and primary care team
- Use a range of outreach methods to engage individuals and
groups in diverse settings
- Share community assessment results with colleagues and
community partners to inform planning and health improvement
- Use effective communication skills.
- Act as a cultural mediator by educating and supporting
providers in working with clients from diverse cultures and help
clients and community members interact effectively with
professionals to promote health, improve services, and reduce
health care disparities.
- Addresses language and cultural barriers to care.
- Coaches and guides member/representative to meet both personal
and clinical goals.
- Assists in scheduling appointments on behalf of
- Work with individuals, family, community members, primary CM
and primary care team to address issues that may limit
opportunities for healthy behavior. This includes completing Social
Determinants of Health (SDOH) screen and other tactics to obtain
barriers to care.
- Provide care coordination, which may include but not limited to
facilitating care transitions, supporting the completion of
referrals, and providing or confirming appropriate follow-up.
- Help bridge cultural, linguistic, knowledge and literacy
differences among individuals, families, communities, and
- Helps member/representative access community and
government-based service agencies including completing paperwork
for the member.
- Helps teach the member/representative and/or care giver about
symptom response plans.
- Participates in the integrated care team meetings and rounds as
- Complies with reporting, record keeping, and documentation
requirements in one's work.
- Use appropriate technology, such as computers, for work-based
communication according to C3 and health center requirements.
- Creates and maintains a comprehensive inventory of local
community resources, improving accessibility for patients and
providers, and linking patients with the appropriate support
- Establishes relationships with community agencies, resources
and supports that are relevant to a Medicaid Population.
- Assist with Medicaid applications, food, and nutrition
benefits, housing applications, coordinating transportation,
- Travel throughout assigned area and engage members at their
homes/ hospitals/community-based locations and or accompany members
to appointments as appropriate.
- As needed, cover other areas in person or via telephonic
- Demonstrate understanding and commitment of the health center
- Demonstrate understanding and commitment to the established CHC
Values and Standards.
- Perform other duties as required or assigned
- High School Diploma
- Bi-lingual (preferred)
- Demonstrated success in working as part of a multi-disciplinary
team including communicating and working with Providers, Nurses,
Social Workers, and other health care teams.
- Experience working with patients with chronic and behavioral
- Must be flexible and adaptable to change.
- Must demonstrate excellent interpersonal communication
- Additional desirable qualities include enthusiasm and passion
for helping patients, genuine spirit, kind, and empathetic nature,
and one who embraces a 'go with the flow' mentality.
- Experience using appropriate technology, such as computers, for
work-based communication, according to organizational
- Experience and proficiency with Microsoft Office and online
- Experience within the ACOs member population preferred.
- Experience working with Medicare, Medicaid and/or Special Needs
- Ability to adapt to a flexible schedule and the ability to work
occasional nights and weekends.
- A valid driver's license and provision of a working
- Demonstrate the ability to work independently.
- Demonstrated organizational and time management skills.
- Demonstrated ability to work independently
- Demonstrated communication skills (verbal and written skills in
In compliance with Covid-19 Infection Control practices per
Keywords: Community Health Connections, Nashua , C3 Community Health Worker - Care Management, Other , Fitchburg, New Hampshire
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