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Community Health Worker

Company: Commonwealth Care Alliance
Location: Springfield
Posted on: November 17, 2021

Job Description:

As an integral part of an Interprofessional Care Team and based on the fluctuating needs of a defined panel of members, the Community Health Worker will engage in regular assessments pertaining to Social Determinants of Health, visit members at regularly scheduled intervals, and conduct urgent visits to ensure that members' Plan of Care is fully comprehensive and addresses significant medical, behavioral, and social needs. The CHW works toward the promotion, prevention, and reduction of health risks. The CHW will support the health education needs of the member in collaboration with the Interprofessional Care Team and PCP.The Community Health Worker will assess health risks and identify gaps pertaining to SDOH which create barriers to member's care and contribute to unmet needs. The Community Health Worker will coordinate with the Care Partner and the member's PCP (Primary Care Provider), as well as CCA's interprofessional clinical care team to identify areas of opportunity, as well as defined resources, and will work in coordination with the team to implement the care plan. In collaboration with the member, the CHW will take ownership of SDOH goals in the member's care plan and will provide input and support for key care management or coordination decisions.The CCA CHW:

  • Facilitates and/or delivers preventative care and health coaching to members according to guidelines set by CCA Clinical Leadership**
    • Identifies and initiates a member agreed-upon plan to resolve areas of opportunity to meet quality
    • Assesses members' social determinants of health (SDOH) through the lens of person-in-environment, and provides support, further evaluation, or coaching as needed to support members in prioritizing their needs and goals
    • Support efforts to decrease hospital readmissions and high emergency department use
    • Supports member retention and connection to Medicaid benefits
    • Provides Diabetes Basics or other health coaching/education to members, as appropriate to support members' goals and care plan
    • Supports health education to members on key quality metrics, including preventive care/screenings
    • Participates in weekly Interprofessional Care Team meetings, as well as ad hoc case conferences when needed
    • Participates in RCA as needed
    • Assists members in obtaining or stabilizing housing, finances, food, utilities, educational/vocational opportunities, and community supports
    • Liaises with CCA Care Partner and community-based PCPs/ Specialists as
    • Ensures accurate and complete documentation of visits and activities within CCA's central medical record and within the record of partners as indicated.
    • Addresses issues regarding substance misuse/abuse, if indicated, in conjunction with Behavioral Health Clinicians and supports
    • Uses recovery strategies such as motivational interviewing, harm reduction, positive behavioral support techniques, limit setting, and strengths-based approaches to support members in attaining stated
    • Provides support and notifies Care Partner regarding changes in: behavior, nutrition, exercise, substance use, medication compliance, housing/resource stability, and other issues as related to the established care
    • Provides 1:1 health education to members regarding chronic disease self-management to prevent and manage health conditions and encourage development of healthy behaviors/habits
    • Provides consultation and support to other members of CCA Care
    • Maintains appropriate written and oral communication on a timely basis, completing documentation within 24 hours of activity, and returning non-urgent calls within 48
    • Actively participates in the evaluation of own performance and progress
    • Participates in on-going education and training to improve skills and role-specific certifications or specialization
    • Participates in CCA quality improvement
    • Assists CCA management and leadership with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and
    • Participates in committees and workgroups that promote clinical excellence and help to advance CCA's mission and businessMinimum Education Required -- Associates DegreePreferred Educational Experience -- Bachelor's DegreeMinimum Years' Experience Required - 3 years' experience in community-based careMinimum Experience -
      • 3+ years working in outreach or in the community with members who have high behavioral health needs and high medical CHW Certified strongly preferredRequired:
        • Strong written and oral skills and the ability to write in a clinical record
        • Strong technology skills in Microsoft products
        • Ability to utilize an Electronic Medical Record and other electronic platforms
        • Ability to use on-line training platforms
        • Ability to review welcome packets and obtain consent forms and attach them to EMREnglish required, bilingual preferredEqual Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Keywords: Commonwealth Care Alliance, Springfield , Community Health Worker, Healthcare , Springfield, Massachusetts

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