Lead Community Health Worker (CHW)

1815

Remote?: 0

Highlights (Bonus, shift, relocation, info for job):

Job Summary

 

The Lead CHW goes beyond Medicine through accountability for building relationships and engaging our new members including locating, supporting with social services, educating on AbsoluteCare services, and enrolling into programs. The role is responsible for establishing trust and building meaningful relationships with AbsoluteCare members and communities. This role meets members where they are, including in the home, community, hospital, or office setting. Outreach includes telephonic and in-person. Additionally, this role will serve coaching and support for all center and community- based peers, and support the Manager in KPI management, reviews, outcomes, and miscellaneous tasks that support the team function.

 

This role is a core member of the interdisciplinary care team (ICT), focused on building trust with members and supporting improved engagement in their medical, social and behavioral health care through promoting compliance with treatment plans.  This involves locating members who have been lost to care or unable to telephonically reach for scheduling hospital/emergency department follow up visits, providing peer support to members in the community setting and connecting members to community resources to meet social determinants of health (SDOH) needs. The CHW primarily interfaces with members in the community setting, including meeting members in their home or community location.

 

The Lead CHW is knowledgeable of community resources and acts as a liaison between members and resources and helps members complete applications to necessary community-based and in-center services. This role establishes and maintains a trusting rapport with members, families, and relevant stakeholders for a specific assignment or for an estimated 3-6 month timeframe, as indicated, and based on the reason for referral.  

 

This role is key to member success in re-engaging in health care through building in-person relationships with members in their home setting, community locations, accompanying to specialist/PCP office visits and other individual community support. The Lead CHW documents all interactions in the electronic health record, attends team meetings, and serves as a community-based liaison for communication between the member and multidisciplinary team.

 

Key performance indicators of this role include successful engagement with members, member adherence in care (e.g., attending PCP and behavioral health appointments), closing social determinants of health (SDOH) gaps, and overall reduction in member hospital utilization.

 

 

Duties and Responsibilities

• Support and educate CHW peers on policies, workflows and procedures that are part of the daily operational function of a CHW team member.
• Monitor and impact Key performance indicators and outcomes that reflect the work of the team.
• Manage an active caseload, consistently meeting and ideally exceeding KPIs and performance expectations
• Assist Manager with various tasks, reporting and projects as needed that enhance or improve CHW team productivity or workflows.
• Conduct research and in-person outreach to locate difficult-to-contact enrollees to increase assessment completion and participation in clinical programs. 
• Conduct in-person non-clinical assessments to understand enrollee care needs, preferences, and socioeconomic barriers, and evaluate the home environment as needed, 
• Promote appropriate utilization of the health care system and AbsoluteCare services to reduce unnecessary ED or hospital admissions.
• Participate in the interdisciplinary care team (ICT) including case consultations, rounds, and follow up.
• Facilitate member enrollment in AbsoluteCare PCP, behavioral health and/or community care management programs
• Support the member to improve their wellbeing
• As needed, help the member engage with mental health and substance use treatment 
• Support the member to ensure pick-up of their prescriptions 
• Provide member education on community resources and benefits 
• Partner with care team (community, providers, internal staff) 
• Effectively build trust and rapport with members and their support systems and communities to drive engagement.  
• Effectively tell the story of AbsoluteCare, its services, benefits and how they can help the specific member being engaged. 
• Connect members with appropriate AbsoluteCare resources if member does not wish to change PCP to AbsoluteCare. 
• Continually find new and innovative ways to build trust and engagement of members located but not engaged and to locate members not found.  
• Identify barriers to care, especially those that have, are currently, or may negatively impact engagement in care or healthcare goals and support addressing those needs including connecting to community resources.   
• Instill and promote AbsoluteCare’s 5-star customer service philosophy in the medical center and in the community by promoting the AbsoluteCare Way. 
• Report and enter daily outreach activities into CRM and electronic health and/or medical record. 

 

 

Minimum Qualifications

 

• Associates degree  
• Must have a valid driver’s license, proof of insurance, and reliable personal vehicle. 
• 5+ years of experience working with community agency providing services encompassing the basic competency areas of health care (community resources, communication skills, individual and family advocacy, health education, services skills and responsibilities). 
• 2-4 years of high performance (exceeding KPIs) and/or proven similar experience.
• Experience leading across peers and identifying and executing process improvements
• Experience and passion for working with and engaging vulnerable, hard to engage, complex populations.  
• Independent and persistent self-starter  
• Proficient in PC skills, such as Microsoft Office. 
• Ability to travel locally at minimum 80% of the time. 
• Knowledge and trusting relationships within local community, and experience and knowledge navigating community resource.  
• Certified as a CHW or eligible to plan to obtain CHW certification preferred 

 

Working conditions

 

This job operates in the community, in member’s homes, and in the AbsouteCare clinical center.  This role routinely uses general office equipment.  It is required that you have and can use your personal vehicle to conduct outreach including member home visits.   

 

Physical requirements

 

• Ability to communicate clearly and exchange accurate information constantly.
• Ability to remain stationary for long periods of time.
• Constantly operates computer, keyboard, copy and fax machine, phone, and other general office equipment.
• Ability to occasionally move objects up to 20 lbs.
• Driving and walking in the community where are members live.

 

Direct reports

 

None.

Why Work at AbsoluteCare?

At AbsoluteCare, we serve the most vulnerable individuals in America. These are our neighbors, people who are at higher risk for disease or who have multiple, complex, chronic illnesses. Often, they deal with an unequal healthcare system and wind up seeking basic care from emergency rooms. We take these patients out of those spaces and turn them into members: people who are entitled to some of the best, most focused care this country has to offer. 

We call this “care beyond medicine.” We have turned the doctor’s office into a comprehensive care center. Here, we surround our members with a core care team of doctors, nurses, social workers, and medical assistants who have the time and skills to get to know our members’ needs. We make the most important services available to our members under one roof. This includes a pharmacy, X-rays, a blood lab, nutrition services, urgent care, and much more.

We don’t stop at our four walls. We engage members in the communities where we all live to find the people who need us most. Through these community care teams, we remove the barriers to healthcare that so many people face daily. And it works. 

Our unique care is guided by our core values of accountability, caring, trust, and teamwork. We call it ACT².

AbsoluteCare, Inc. provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, age, disability, genetics, protected Veteran status, or any other characteristic protected by law or policy.

EEO Employer Verbiage: AbsoluteCare, Inc. provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, age, disability, genetics, protected Veteran status, or any other characteristic protected by law or policy.