The ACO Community Health Worker (CHW), under the guidance of the Director of Population Health, is a vital part of the integrated care team. They'll play a key role in care coordination, focusing on patients with Health Related Social Needs (HRSN). This includes conducting assessments, developing care plans, engaging patients, and managing transitions of care. They'll serve as a liaison between ACO members and community-based service providers.
Key Responsibilities
- Manage a caseload of 60-70 patients, enrolling 13-15 new patients monthly. Conduct HRSN screenings, develop and implement individualized care plans, provide health education, and facilitate access to essential services (housing, food, finances, etc.). Monitor patient progress and adjust plans as needed.
- Build trusting relationships, implement strategies for hard-to-reach patients, conduct home visits, and accompany patients to appointments to ensure compliance.
- Follow up on post-discharge referrals to mitigate readmission risks, escalate barriers to the primary care team, and participate in pre-visit planning.
- Maintain accurate EHR documentation, perform chart reviews, communicate patient updates to the ICT team, and participate in ACO meetings.
- Commit to professional growth, including acquiring and maintaining relevant certifications.
Shift/Hours: M - F 8:00am - 4:30pm OR 8:30am - 5:00pm (3 days onsite and two days remote to travel to see patients or do paperwork.)
Must Have Skills/Qualifications:
- Bilingual in Spanish
- High School Diploma
- Open to obtaining a CHW certification within 6 months (paid for by client).
- Valid drivers license and a vehicle to meet patients at appointments if needed.