Community Health Worker [Senior Associate] - Washington DC

Community Health Worker (Washington DC)

The Community Health Worker (CHW) will serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. This involves collaboration and continuous partnership with client's staff, primary care practices practitioners & staff, their patients and their families/caregivers, clinic/hospital/ specialty providers, and community resources -- in a patient-centered collaborative care environment. The CHW will build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy. The Lead Care Manager will provide clinical supervision and oversight of the CHW.

This is a staffing position and will report to the assigned Clinical Care Manager.

Responsibilities & competencies

• Promote timely access to appropriate care
• Increase utilization of preventive care
• Reduce emergency room utilization and hospital readmissions
• Increase comprehension through culturally and linguistically appropriate education
• Work with beneficiaries to plan and monitor care:
• Assess beneficiaries’ unmet social needs
• Provide community resources to the beneficiaries to assist with food, housing, mobility, energy assistance, childcare, and other governmental programs
•  Educate patient and family/caregiver(s) about relevant community resources
• Develop an intervention plan with the patient, family/caregiver(s) providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate) and Lead Care Manager
• Monitor adherence to intervention plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed
• Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the intervention plan regarding transitions-in-care and referrals
• Attend or call-in for daily and weekly rounds. Weekly rounds will include a review of all beneficiaries on CHW caseload and those in outreach (referred)
• Responsible for at least two outreach days in the community. Communicate with Care Team and Lead Care Manager to provide enrollment and progress updates
• Share beneficiary concerns with the Care team including, but not limited to, changes to social barriers, changes in schedule and rounds
• Notify the Lead Care Manager when a beneficiary has case management or additional assistance need.
• Assist beneficiaries at social services and social security visits for SNAP, TCA, and TDAP when applying for SSI/ SSDI and insurance
• Complete home and hospital visits to assist with enrollment for CHW services and to improve participant engagement
• Provide applications to organizations and in-person follow-up with beneficiaries
• Attend clinical mandatory training to improve beneficiary communication and clinical skills
• Provide documentation, in preferred practice platform, detailing efforts, resources, and communications with beneficiaries
• Document patient progress and treatment recommendations in EHR and other required systems
• Facilitate referrals for social services such as food, housing, mobility, energy assistance, childcare, transportation, and other governmental programs
• Facilitate encounters between the patient, family/caregiver(s), care team, payers, and community resources, as needed
• Attend all MDPCP training courses/webinars and meetings
• Provide feedback for the improvement of the Health Services for Children with Special Needs (HSCSN) Care Management Program
• Perform other duties as required.
• Success in this position will lead to improved physical and mental health for the patient and reduced health care costs for the managed population of patients.

QUALIFICATIONS

• BA or BS degree required
• 1-3 years’ experience working in community health care settings is required
• Local knowledge about and connections to community health care and social welfare resources is desirable
• Must have a strong team building, leadership, and mentoring skills.
• Must have high organizational, performance management, and problem-solving skills.
• Have high emotional intelligence and exceptional communication skills.
• Must have influencing skills that foster a collaborative and continuous-improvement environment.
• Proven ability to lead, motivate, and build cross-functional teams that deliver services and solutions that surpass client expectations.
• Proficiency in communication technologies (email, cell phone, etc.)
• Highly organized with the ability to keep accurate notes and records
• Experience with health IT systems and reports is desirable
• Must be customer/patient-focused.
• Contribute to high-quality deliverables and/or tasks under supervision. 

In addition to the above qualifications the successful incumbent is expected to consistently demonstrate:

• Core values consistent with a patient- and family-centered approach to care
• Demonstrates professional, appropriate, effective, and tactful communication skills, including written, verbal and nonverbal
• Demonstrates a positive attitude and respectful, professional customer service
• Acknowledges patient’s rights on confidentiality issues maintains patient confidentiality at all times and follows HIPAA guidelines and regulations
• Proactively acts as a patient advocate, responding with empathy and respect to resolve patient and family concerns, and recognizes opportunities for improvement to meeting patient concerns
• Proactively continues to educate self on providing quality care and improving professional skills

REQUIREMENTS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

 Work is generally performed remotely or within the office environment, with standard office equipment available.  While performing the duties of this job, the CHW is regularly required to talk or hear, stand, walk, sit; use hands to finger, handle or feel objects, tools, or controls; and reach with hands and arms. The CHW frequently lifts and moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus. The CHW is expected to complete onsite visits with patients by driving to their homes, physician offices, and other healthcare facilities. The CHW is required to document client-related activities and conversations on their laptop in our client database within 48 hours of the client interaction. Work may be performed at the client site and/or Medicalincs offices.  Travel will be required.  Work is mostly sedentary in nature but may require occasional standing and walking.  Lighting and temperature must adequate, with no hazardous or unpleasant conditions caused by noise, dust, etc.  Must have good vision and be able to read, write, and communicate fluently in English.  Occasional working overtime may be required to meet project deadlines.

ABOUT MEDICALINCS

Medicalincs is a renowned healthcare business & clinical management services firm that supports health organizations to improve organizational performance by providing less expensive, human-centered, integrated, managed care solutions. We have significantly improved health outcomes, cost savings, and return on investment for our clients. Medicalincs is was launched in 2017. We are located at Silver Spring, Maryland, and serve the Maryland, District of Columbia, and Virginia regions.

Medicalincs has a Care Transformation Organization (CTO) known as Healthlincs www.healthlincs.org and we provide direct care management support for primary care practices participating in the Maryland Primary Care Program.

OUR MISSION:  At Medicalincs, our mission is to link silos in the healthcare system -- to achieve the most cost-effective, high quality, and continually-improved care delivery that preserves & saves lives!

OUR PHILOSOPHY:  To make a difference, you need to be THICK - Trusted, Hearty, Innovative, Committed, & Kaizen!

Medicalincs brings a unique understanding of healthcare delivery systems across healthcare settings & payer groups; and in-depth experience applying strategic fusion of clinical, business, and technical expertise -- to drive comprehensive and tried-and-true lasting solutions to advance networks and population health management. Our areas of expertise include: Managed Care & Care Value | Care Delivery Model Transformation Implementation | Quality Improvement & Patient Safety | Program Management & Change Management | Program Evaluation & Data Analytics | Organizational Development & Strategic Planning.

• Are you on a mission to continually improve healthcare solutions that preserve & save lives? MEDICALINCS  offers you:
  
• A balance of work, life, & fun -- with a close-knit team of professionals! 
  
• Delivery of top-notch health care solutions to our clients
  
• An innovative and creative environment, with diverse highly talented co-workers
  
• Empowerment to perform at your highest potential and opportunity to grow
  
• Recognition for being part of a talented team & Reward for performance