Community Health Worker

The Community Health Worker work entails outreach to patients, engaging them in care management, setting up routine contacts and tracking and follow-up, co-creating care plans with them using motivational interviewing techniques, working on self-management goals, providing links to outside resources when needed, follow-up after any hospitalization or ED visit, and documentation of each direct patient contact or interaction about the patient with others on the care team. This role tightly works with the RN Care Manager, with daily huddles reviewing patients needing follow-up today/this week, any challenges happening, new patients engaged, and understanding when the care manager should be brought in to talk with the patient, and when a case review with the PCP is needed. Scheduled Hours: 37.5 hours per week Complete all required training sessions and activities. Use outreach tools and technique to contact patients and engage then in the Complex Care Management program. Build rapport and connection with patients in an empathetic manner. Collaborate with patient (and family/advocate at patient request) to understand their health care needs and goals. Develop with the patient a care pla