Summary of Position
The Patient Care Community Health Worker (CHW) works in collaboration with the Care Coordinator to evaluate patient progress toward goals, assist with the coordination of care with the clinic providers and staff, and other community resources in a team approach to the below. This is a grant funded position and may or may not be extended or approved as a permanent position.
• Promote timely access to care, utilizing resources to remove barriers to care.
• Increase utilization of preventive care with motivational interviewing techniques.
• Document in developed care plan and communicate with RN Care Coordinator patient progress toward goals.
• Increase continuity of care by managing relationships and communication with tertiary care providers, transitions-in-care and referrals.
• Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction and reducing health care costs.
• Increase comprehension through culturally and linguistically appropriate education.

Principal Duties and Responsibilities
• Assist patient in access to care by utilizing resources as needed, such as transportation
• Work with patients to plan and monitor care:
a) Monitor adherence to ordered action plan, care plan, and promote progress to complete. This includes, but not limited to, reviewing charts prior to patient visit to identify open testing and referral orders
b) Create ongoing relationships with patients and family/caregiver(s) to determine and request care coordination support they need or desire
c) Communicate with care team, Practice Manager, RN Care Coordinator and document appropriately
• Educate and assist patient and family/caregiver(s) about relevant, needed community resources (In response to HIV, Depression Screenings, and Social Determinants of Health questionnaire (PRAPARE), as well as other needs identified by PCP team)
• Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up and reports.
• Appropriately, and timely, document activities in the patient’s EHR within scope of practice
• Attend Community Health Worker training courses, webinars, meetings, etc. to remain current on regulations, practices, etc.
• Assist team in processing and completion of referrals and testing for all patients
• Assist patient to complete required paperwork and online requirements, as needed, for Medicaid enrollment
• Assist patients with language barriers (through Interpreter) or low literacy complete necessary forms
• Perform other duties as assigned

Required Skills or Abilities
1. Ability to manage and prioritize multiple tasks.
2. Working knowledge of EHR, Next Gen preferred
3. Proficient in Excel, Word and PowerPoint and ability to learn other computer programs.
4. Good organizational and self-management skills
5. Excellent verbal and written communications skills
6. Ability to communicate with a diverse range of people, from physicians to the patient population.
7. Demonstrates knowledge of, and adherence to patient’s rights, confidentiality and HIPAA guidelines and regulations
8. Knowledge of local community health and social welfare resources preferred
9. Ability to relate well to people from diverse ethnic and cultural backgrounds
10. Demonstrates strong working knowledge of PCMH processes and guidelines

Required Knowledge, Experience or Licensure/Registration
1. Previous experience in clinical or community resource setting required.
2. Community Health Worker (CHW) Certification preferred, or associate or bachelor’s degree with previous Community Health Worker experience. CPR certification required.
3. Knowledge of Community Health Centers preferred.