SUMMARY OF RESPONSIBILITY:

The Community Health Worker (CHW) works in a team environment and supports the care management and coordination activities of the care team. Under the direction of the clinical team, responsibilities include but are not limited to coordination of community resources (i.e. transportation to medical appointments, town services, clinical home services, etc.), SDOH/SIOH screenings, administrative tasks such as mailing educational materials and letters, scheduling patient appointments, locating and obtaining outside patient records, and other critical tasks to support the care management team.

Essential Functions:

• Has a working understanding of patient care delivered in the ambulatory setting and also values the vision and strategies of Population Health to become more accountable for better care, better experiences and reduced healthcare costs for the populations being served.
• Assist patients and/or caregivers in scheduling patients’ appointments and access services as needed.
• Collaborate with community partners, such as providers, VNA agencies, caregiver programs, and DME providers.
• Use general knowledge of medical conditions, nutrition, and diet to educate patients. Act as a resource to providers and support their plan of care.
• Assist in locating and obtaining patient clinical records; enter pertinent information into patient electronic health record.
• Facilitation of patient and caregiver access to community resources relevant to patient’s needs, including referrals to transportation programs, Meals on Wheels, senior centers, chore services, etc.
• Provide motivation, guidance, support, and encouragement to build relationships with target population to promote positive health and social service outcomes. Work with the care team to achieve care plan goal completion, with transition of patient to inactive or graduated status as appropriate.
• Coordinate incoming and outgoing information and other various administrative tasks needed to support the team.
• Attends required meetings and participates in committees as requested and assists with special projects as needed.
• Cultivates positive relationships with all patients, customers, guests, and members of the care team.
• Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Trinity Health’s Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures to ensure adherence in a manner that reflects honest, ethical, and professional behavior.
• Screen patients to assess for depression, tobacco use, unhealthy alcohol use, other substance use, and preexisting mental health disorders; when any screening is positive, respond with appropriate interventions and/or referrals.
• Screen pediatric patients for SNAP and WIC eligibility and provide patients and their families who are eligible for SNAP and WIC application assistance.
• Conduct activities such as but not limited to team-based huddles, activities on behalf of patients at the site, or patient-facing activities.
• Participate in team activities such as team huddles, i.e., standing team meetings for the purpose of pre-visit planning, population health management, process improvement, etc.

Other Functions:

• Performs other duties as assigned.

The duties listed above are intended only as illustrative of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar or a logical assignment to the position.

QUALIFICATIONS AND COMPETENCIES:

• High school diploma required.
• Medical Assistant Certificate preferred. Associates degree or equivalent medical experience preferred. Qualified as a Certified Application Counselor for MassHealth program or is willing/able to complete required trainings to support patients in demonstrating eligibility requirements for Medicaid in Massachusetts on an ongoing basis.
• Qualified as a Certified Application Counselor for MassHealth program or is willing/able to complete required trainings to support patients in demonstrating eligibility requirements for Medicaid in Massachusetts on an ongoing basis.
• Minimum of five years’ overall work experience. Experience addressing the Behavioral Health (BH) and Health Related Social Needs (HRSN) of children, youth, and families in a health care setting and/or possessing specialized training, degree, licensing, or certification in such work.
• Minimum of two years' experience within a healthcare related organization (e.g. health system, hospital, clinic, provider practice, health insurance company, pharmaceutical company, etc.) required.
• Bilingual candidates are encouraged to apply.
• Excellent organizational skills required, with the ability to communicate and work collaboratively with all levels of staff, payors, providers and office staff, and effectively utilizing all resources available.
• Requires culturally Competent Interpersonal & Communication Skills. Ability to read and comprehend complex instructions, short correspondence, and memos. Ability to write complex correspondence. Service requires proofreading and checking documents for accuracy. Ability to effectively interview patients/caregiver and accurately record medical information. Ability to effectively present information in one-on-one and small group situations to patients/caregiver, and other employees of the organization. Ability to effectively relate pertinent information with medical and social service professionals.
• Must be adaptable to unpredictable situations in a patient care setting while effectively managing assigned duties with precise attention-to-detail, accuracy and follow through, with minimal supervision.
• Maintains strict confidentiality with patient information in a professional manner.
• Ability to use computer software and Microsoft Office applications, including Excel spreadsheets, is required.
• Ability to perform job with integrity and values consistent with the organization’s Mission, Core Values and Standards.
• Ability to travel to hospitals, skilled nursing facilities, patients’ homes, and other sites where patients receive care (as indicated by patients’ needs).
• Must possess excellent interpersonal skills, with a flexible and creative approach to problem solving. Ability to facilitate discussion and build consensus.

Physical and mental requirements :

• Concentrates, organizes efficiently and independently organizes work.
• Assumes cross coverage responsibilities.
• Physical effort involved in walking to conduct interdepartmental business.
• Position requires ability to occasionally lift light objects; frequently performs moderately difficult manipulative, gross body coordination and hand-eye coordination tasks; walks, stands and sits for prolonged periods; sees objects closely and hears normal sounds with some background noise.
• Ability to frequently concentrate on fine detail with interruption and attend to tasks for more than 60 minutes at a time.
• Individual must be able to understand and relate to theories behind several related concepts, remember multiple tasks given over long periods of time and be able to communicate in written word using advanced written skills.
• Driver's license and ability to travel at least 50%.

Role includes combination of remote and onsite work with candidate residing in CT or MA.

ADDITIONAL REQUIREMENTS: As a condition of employment at SoNE HEALTH and for the safety and well-being of our employees:

• All employees are required to be fully vaccinated for influenza and COVID-19.

• All employees must reside in New Hampshire, Rhode Island, Maine, Vermont, Connecticut, or Massachusetts.

• If you will be working from home occasionally or permanently, we require a stable internet connection. We recommend that you have an internet service provider with speeds of at least 30Mbps download/5Mbps upload. Please visit speedtest.net to verify your internet speed.

SALARY: $46,729 - $60,748