Community Health Worker/Navigator (51884)

As a Community Health Worker, you will support the healthcare team by providing patient coaching and conducting motivational interviewing to support patients, families, and caregivers in achieving self-management, self-efficiency, and behavior changes to improve patient health and care outcomes. You will also assist in referring our patients to various community resources. This Rural Health Transformation Program is supported by the Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $206,927,896.80 with 100 percent funded by CMS/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CMS/HHS, or the U.S. Government.

JOB RESPONSIBILITIES:

• Establishes trusting relationships with patients and their families while providing general support and encouragement.
• Provides ongoing follow up, basic motivational interviewing and goal setting with patients/families.
• Serves as a liaison between clinical staff and patient, by following up with patients regarding their appointments, referrals, and needed resources.
• Helps patients set personal goals and attend appointments.
• Provides referral for services to community agencies as appropriate.
• Helps patients connect with transportation resources and gives appointment reminders to aid in compliance with prescribed plan of care.
• Helps patients connect to needed resources to carry out plan of care (MOWs, HH, Prescription assistance, etc.)
• Works closely with integrated medical team to ensure that patients have comprehensive and coordinated care.
• Remains knowledgeable about community resources appropriate to needs of patient/family.
• Continuously validates and evaluates the effectiveness of the community resources.
• Provides consistent communication to Medical Provider/Care Team Nurse to evaluate patient/family status and reports progress and compliance with identified plan of care.
• Enables and improves culturally and linguistically competent services and care by making efforts to understand the community culture and resources.
• Conducts outreach, implements programs in community that promotes, maintains and improves community health needs and provides resources.
• Collects data to help identify community health needs.
• Advises community groups on chronic disease and diabetes self- management, hypertension, and nutrition.
• Advises clients on general health and exercise and self- care activities.
• Identifies age appropriate needs and resources.
• Follows up hospitalizations and no shows
• Provides situation appropriate social support to the patient utilizing experience lived and learned through training provided at HL
• Provides informal counseling as needed.
• All HealthLinc staff is committed to engage in quality improvement initiatives that align with and support Patient-Centered Medical Home (PCMH).
• Performs other duties as assigned.