Job Summary:

As the Community Health Worker, you will contribute to improving the health of communities and individuals by screening for Health-Related Social Needs (HRSNs), connecting them to services, and providing health education and community resource support. You will work together with healthcare systems, social service providers, and community-based organizations to make resources more accessible and improve the quality-of-service delivery through your compassionate, culturally competent support and coordination. 

 Responsibilities: 

Screening and Documentation: 

Complete screenings of the patient population for Social Determinants of Health (SDOH).  Document findings in EPIC and other required platforms. 

Navigation Services: 

Work with Medicaid Members to connect them to the appropriate services to address their HRSNs that align with the Members’ preferences.  Document interventions in EPIC and other required platforms.  Assist member with scheduling transportation through MAS or other available/appropriate resource.  Follow up with the Member to confirm the services were accessed and understand if their needs were met.  Establish and maintain relationships with community agencies, service providers, and stakeholders to stay informed about available resources and referral pathways. Maintain up-to-date knowledge of community resources appropriate to the needs of participants/families and act as an advocate between the participant/family and community service agencies. 

Support for Preventative Care: 

Assist patients in completing preventative screenings, healthcare visits, immunizations, etc., as identified through Health Maintenance or payer quality measure reports. 

Cohort Intervention: 

Manage assigned caseload of Medicaid members  Provide support for people with behavioral health diagnoses and/or people who use drugs without using stigmatizing language or practices. Communicate compassionately with all individuals seeking services.  Remove barriers to access otherwise present due to the individuals’ limitations, disabilities, resources, etc.  Develop Social Care Plans for eligible Members that include a summary of Member needs, eligibility, services to which Members are referred, and status of those referrals. Update Social Care plans as needed.  Monitor and respond to communication(s) received from Members.  Promote appropriate use of healthcare resources by fostering a consistent connection with primary care.  Educate patients on when to use walk-in clinics or the Emergency Room. 

Attribution Management: 

Outreach to attributed patients that are not scheduled for appointments.  Notify payers of patients who are in fact attributed to non-Guthrie PCP.

Qualifications: 

High school diploma or equivalent; additional education/experience in healthcare or social services is a plus.  Experience working with Medicaid populations and understanding of social determinants of health (SDOH).  Possesses strong communication skills (written and verbal).  Communicates compassionately and professionally with all individuals seeking assistance.  Empathy and a commitment to improving patient outcomes.  Navigate complex systems of care with critical thinking, patience and perseverance.  Negotiation skills and the ability to develop strong working relationships  Proficient in planning & time management  Possesses adaptability skills (both in attitude and action). Ability to work independently with minimal supervision, and as part of a team.  Must have strong personal computer program skills including Microsoft Outlook, Microsoft Office (Word, Excel PowerPoint etc.)  Participation / facilitation of meetings either in person or via virtual platforms such as Teams, Zoom 

Preferred Qualifications: 

Certification as a Community Health Worker.  Proficiency in using EPIC or similar electronic health record systems.  Familiarity with the U.S. healthcare system and federally funded healthcare programs  Bilingual skills. 

Working Conditions: 

This position may require travel within the community to meet with patients and Community Based Organizations.  Flexibility in working hours to accommodate patient needs.  May assume additional responsibilities, as required.

The pay ranges from $20.38-$31.81  per hour