POSITION SUMMARY

The Community Health Worker supports the Michigan Community Health Network (MCHN) to reach and engage Medicaid beneficiaries related to their health and healthcare.

The Community Health Worker facilitates communication between patients, their families, caregivers, providers, and other members of the health care team. In addition, carries out delegated functions related to disease states and other conditions that have been deemed to be part of the scope of practice for unlicensed staff members. The focus is to offer individualized assistance to patients, families and caregivers in order to help overcome health care system and community barriers and help facilitate consistent and timely medical care across the continuum of care. The Community Health Worker functions as members of the integrated care delivery team.

The Community Health Worker supports health centers in providing telephonic or virtual care coordination for patients with complex chronic conditions through a patient-centric approach. In collaboration with the clinical team, creates, implements and monitors care plans to ensure patient compliance and optimize health outcomes. Performs all responsibilities according to clinical pathways and evidence-based best practices.

RESPONSIBILITIES AND DUTIES

• Utilizes patient registries and lists to identify at-risk patients who will benefit from care management, particularly patients with multiple, chronic conditions.
• Engages plan members that are identified as at risk or high need and completes health risk assessments and encourages connection to local health center services. These include Primary Care Providers, RN Care Management, Behavioral Health, Substance Use Disorder or Community Health Worker services.
• Monitors admissions, discharges, and transfers (ADT) reports and encourages engagement with local health center / PCP for transitions of care.
• Assures completion/documentation of a comprehensive patient assessment; medical, functional, cognitive, affective, psychosocial, nutritional, and environmental; collaborates with clinical team to address gaps in assessments as needed. Coordinates evidence-based care planning with the patient/family.
• Assists the patient in developing realistic self-management goals and identifying barriers to success for those goals; supports patient in overcoming barriers for unmet goals. Monitors the patient, assessing progress on self-management goals, and if current goals met, guides the patient to set new goals.
• Provides medication management and adherence education within scope of care management and scope of license.
• Coordinates care across all healthcare settings, including ambulatory care, hospitals, emergency departments, skilled nursing facilities, rehabilitation facilities or other clinical sites.
• Reviews social determinants of health (SDOH) screenings; coordinates referrals to community resources to address accordingly.
• Identifies education related to patient learning needs and to assess patient’s knowledge, skill level and readiness for learning and adherence to care plans.
• Develops and/or acquires educational materials, supplies and equipment necessary for patient learning and to optimize clinical outcomes.
• Periodically reviews with clinical team patient status updates and collaborates to further develop or revise care plans.
• Participates, if required, in clinical team huddles/rounds (virtually) as appropriate.
• Provides education, as needed, to health centers on quality metrics, initiatives, and activities to support improved patient outcomes.
• Engages in ongoing practice improvement processes, both with the health centers and MCHN.
• Other duties, as required.

KNOWLEDGE, SKILLS AND ABILITIES

Knowledge of, or dedication to learn:

• Public and private healthcare services and clinical standards of care.
• Performance/quality improvement concepts, processes, and methodologies.
• Primary care workflows and nationally identified clinical best practices.
• Chronic health conditions, evidence-based guidelines, prevention, wellness, health risk assessments and patient education.

Skill/Ability to:

• Be able to manage multiple tasks and projects at the same time, and strong organizational skills.
• Communicate effectively with individuals from varied professional backgrounds and diverse cultures verbally and written.
• Use efficient time management skills.
• Use creativity in problem-solving.
• Support and collaborate with other members of healthcare teams without a direct supervisory position.
• Communicate clinical information in a clear and concise manner (verbally and in writing).
• Work comfortably and effectively in a self-driven, rapidly changing environment.
• Experience or willingness to learn Microsoft Outlook, Word, Excel and electronic Population Health tools.

Education/Experience:

• Minimum of one year experience in direct patient/client service exercising one or more Community Health Worker (CHW) core roles (providing culturally appropriate health education, care coordination, coaching and social support, individual and community assessment, conducting outreach etc.)
• Completion of Michigan Community Health Worker Alliance (MiCHWA) CHW training and certification, or a substantially similar training/certification program within 6 months of hire.
• Experience working directly with people from diverse racial, ethnic, and socioeconomic backgrounds.

Additional Position Terms

Location: Hybird in Michigan with some in-office expectation