Key Duties and Responsibilities
-
Find member populations that are difficult to locate (homeless, severe mental illnesses, substance use, medically underserved, in need of preventive services, etc.)
-
Support members in improving their whole health, through outreach and engagement activities, which are primarily field based
-
Enroll members into programs and services by effectively communicating their value
-
Work with members to provide effective and efficient service coordination
-
Collaborates and consults with Case Manager on member care issues that is clinical based
-
Provide on-site/in-home member assessments for safety risk, health needs, and barriers to care
-
Develop service plans and guides with members and providers that include health management goals
-
Engage with members, both in-person and on the phone, to achieve health management goals using health coaching, motivational interviewing, and problem solving techniques
-
Assist members in overcoming any barriers to meeting health goals and update service plans accordingly
-
Assist members in scheduling appointments and accessing community resources
-
Assist MSW as needed
-
Accompany, arrange for, or directly provide, member transportation to health services appointments
-
Follow up with members via phone calls, home visits, and visits to other settings where members can be found
-
Work with social service agencies to arrange to meet other member needs (housing, food, clothing, financial assistance, etc.)
-
Work with facilities to help transition members after discharge to a safe home environment
-
Maintain accurate, quality, timely, and consistent documentation in company database of member activities and interventions
-
Achieve set goals/KPI's
-
Continuously expand knowledge of community resources, services, and programs available to members and build ongoing relationships with these organizations to advocate for members
-
Performs other duties as assigned
Education and Experience
-
High School Diploma/GED required
-
Bachelor's Degree preferred
-
Community Health Worker Certificate preferred, or have at least minimum of 2 years experience working in health, social, or community services
Essential Skills and Abilities
-
Knowledge of community resources within the community to be served
-
Represent the company with professionalism by maintaining clear professional boundaries with members and coworkers
-
Working knowledge of social and health issues
-
Ability to quickly establish credibility and trust with patients and build strong relationships
-
Sound judgment and the ability to quickly analyze situations
-
Ability to establish priorities and meet deadlines
-
Ability to problem solve in a proactive, creative manner
-
Cultural competency- able to work with diverse groups of community members
-
Technologically knowledgeable or experienced in note entry systems, smart phones, and laptops
-
Experience providing peer support to patients with complex and multiple chronic conditions and challenging social and mental health conditions (e.g. Community Health Worker, Patient Navigator, In-Home Support Specialist, etc.).
-
Training or experience in community health, social determinants of health, and peer counseling.
-
Training and experience in using Motivational Interviewing strongly preferred
-
Strong interpersonal and social skills with demonstrated ability to collaborate with a variety of individuals from a wide range of professional and personal backgrounds.
-
Knowledge of community-based healthcare and social services systems and the needs of medically underserved populations, and older adults/seniors
-
Ability to thrive in a complex and rapidly changing environment.
-
Maintains confidentiality and follows HIPAA standards in safeguarding patient information.
-
Good oral and written communication skills.
-
Knowledge and/or experience within Home support Services (IHSS) is highly desirable.
-
Life experience overcoming the challenges of chronic disease or work experience with people living with complex chronic conditions is highly desirable.
-
Thrives in an unstructured, start-up environment.
-
Self-starter that can work independently and collaboratively, prioritize tasks and has initiative and excitement to take on unfamiliar tasks.
-
Excellent communication and interpersonal skills with the ability to effectively communicate with all levels of management, patients, and family members.
-
Creative, flexible, well organized, resourceful, and detail-oriented.
-
Excellent judgment in handling confidential and sensitive information
-
Ability to work independently, set priorities and handle multiple tasks with a high level of efficiency
-
Establishing and maintaining cooperative working relationships with others
-
Bilingual (Spanish) preferred, but not required
Core Competencies
-
Instills trust
-
Customer focus
-
Manages ambiguity
-
Collaborates
-
Drives results
