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About the Role

The Community Health Worker - Transitions of Care (CHW-TOC) works in collaboration with patients, families, and staff to provide care coordination and resource information for patients in the hospital and health center setting, reporting to the Manager of Community Health Social Services (MCHSS).

Responsibilities

• Facilitates and supports hospital transitions to care to CommUnityCare Health Centers.
• Creates new patient charts to assist patients in establishing care.
• Collaborates with all team members of the hospital care team.
• Collaborates with external partners, including hospital staff and Central Health, on patient transitions for complex care.
• Attends daily patient care (unit) huddles and periodic informational (clinic) huddles, meetings, patient conferences, or planning sessions.
• Participates in the identification and intervention of Social Drivers of Health needs for internal and external referrals.
• Acts as a patient and family advocate to ensure services are delivered to meet patient and family needs and for appropriate resource utilization.
• Coaches and supports patients through financial screening application processes.
• Completes all direct and indirect care documentation in a timely manner and ensures patient records are current and complete.
• Supports transitions of care to primary care providers across CommUnityCare health centers.
• Maintains ongoing communication with community partners and attends community events to promote education and awareness of safety net programs.
• Collaborates with all members of the care team in providing patient-centered care.
• Provides cultural mediation between community members and CommUnityCare.
• Empowers patients and/or their families to be engaged and active participants in their care.
• Helps patients and families set personal goals and attend appointments.
• Coaches patients in effective management of their health conditions and self-care.
• Serves as a liaison between the patient and healthcare systems, assisting as needed.
• Interfaces with providers and clinic team to ensure patients follow the provider’s treatment plan.
• Interacts with patients via phone calls, medical or social services appointments, and other locations per program guidelines to bridge the gap between systems.
• Advocates for individual and community health needs and performs outreach activities within the community.
• Maintains privacy and confidentiality of patient’s medical records and visits.
• Ensures all tasks provided comply with all regulatory and accreditation standards including The Joint Commission and CommUnityCare Standard Operating Procedures and Policies.
• Develops and maintains favorable internal relationships and partnerships with co-workers, clinical managers, clinical support staff, providers, and business office staff.
• Interacts respectfully and collaboratively with patients and their families, striving to develop favorable relationships.
• Participates in quality strategies to evaluate compliance with evidence-based guidelines and standards and to identify opportunities to improve patient outcomes.
• Attends seminars and maintains all licensure and/or certification requirements for continuing education and best practices.
• Seeks opportunities and implements goals for own professional development.
• Performs other duties as assigned.

Requirements

• Graduated from a high school or equivalent.
• 2 years of experience working within a community health setting in a health care role or a community based human service agency as a Community Health Worker (CHW), health educator, community outreach worker, or community organizer.
• Certified Community Health Worker (CHW) or completion of an approved 160-hour competency based Community Health Worker training program certified by DSHS within the first six (6) months of hire.
• Valid Texas Driver’s License with no outstanding driving violations.
• Access to personal vehicle with proof of insurance.

Skills

• Strong interpersonal skills.
• High level of skill at building relationships and providing excellent customer service.
• Excellent verbal and written communication skills.
• High level of problem-solving skill.
• Strong attention to detail and accuracy.
• Excellent skills in public speaking.
• Ability to communicate in various settings, including group presentations and small-scale meetings.
• Bilingual (Spanish/English) preferred.
• Ability to work with diverse groups of people.
• Demonstrated familiarity with tools, technology, and systems typically found within most health care environments (i.e. EHR, personal computer skills, including Microsoft Office).

Location

• hospital and health center setting

Work Type

• full-time

Experience Level

• 2 years of experience

Education Level

• High school graduate or equivalent

About the Company

• CommUnityCare Health Centers