• Work under the guidance of an RN Care Manager
• Conduct initial outreach calls to encourage patients and caregivers to participate in care management programs
• Document activities in the Identifi system, including care plan activities conducted.
• Engage with patients in person who need assistance with self-care needs beyond what a nurse care advisor can provide via phone
• Address language and cultural barriers to care and self-care
• Coach and guide the patient to meet both personal and clinical goals
• Schedule provider visits on behalf of their patients
• Accompany patients on their visits and remind patients of their upcoming visits
• Help patients access community and governmental service agencies including possibly filling out paperwork with/for the patient
• Help teach the caregiver about symptom response plans
• Facilitate closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testing
• Participate in the integrated care team meetings and is reliable
• Participate in community health fairs and events

Skills: Outreach Calls, Documentation, Patient Engagement, Cultural Sensitivity, Goal Coaching, Appointment Scheduling, Community Resource Access, Care Team Collaboration

• Conducts home, virtual, or telephonic visits to identify functional, social, emotional, and knowledge-based barriers to care.
• Findings and recommendations are reviewed with the Social Services and Clinical Services team to collaborate in Care Plan development
• Identifies service needs related to health concerns, and urgent member safety issues, and escalates to the next level 
• Collaborates with Clinical Services and Welcome Wagon teams on non-clinical fieldwork
• Face-to-face visits with members at home, at nursing homes, in shelters, and/or in doctor’s offices.
• Executes home safety evaluations and in-home fall risk assessments
• Comprehensive knowledge of the local community and public resources including qualification criteria, application process, and onboarding workflow
• Utilizes department desktop procedures, workflows, job aids, and training material.
• Identifies barriers to work processes and brings to the attention of the supervisor/manager
• Completes all assessments, visit documentation, and paperwork promptly.
• Maintains HIPAA compliance, and quality of care standards as defined by the medical group, health plan, and CMS
• Facilitates members’ health through advocacy, understanding, education on health plan benefits, appointment scheduling, support systems/team development and reinforcement of self-management tools
• Assists members and caregivers in taking an active role in health management and promotion, through coaching, education, navigation, goal setting, and referrals to appropriate care and community-based resources
• Utilize motivational interviewing techniques to help members identify and understand their intrinsic goals and motivate members to engage in positive behavior changes

Skills: Home Visits, Care Plan Collaboration, Service Needs Identification, Fieldwork Collaboration, Safety Evaluations, Community Resource Knowledge, Documentation, Motivational Interviewing

• Administer screening assessment tools to assigned populations, according to the clinical guidelines.
• Follow-up with patients according to their care level, helping the patient understand their disease processes, and their healthcare provider’s instructions.
• Provide follow-up to any referral plans provided by the primary care physician or care team.
• Intake of blood pressure, drug reconciliation, body mass index, and glucose levels, among other clinical values according to the patient’s health needs.
• Maintain minimum active patient caseload and document in the care management tool according to approved flowcharts.
• Ensure primary care and specialty appointment instructions are understood.
• Track and report patient encounters, and clinical values, and maintain required records.
• Maintain appropriate confidentiality of information.
• Coordinate appointments with physical and mental health providers in real time.
• Provide client follow-up and monitoring, including phone calls and home visits with patients 
• Collaborate with the team to provide clients with the opportunity to manage and improve health, coordinate care, and provide the clinical team with case findings.
• Provide education regarding the identified health needs of the assigned population.
• Serve as liaison between state agencies and local community programs.
• Assist patients in understanding their insurance and medication coverage.
• Assist patients in connecting with community resources.
• Actively participate in required training and professional development activities.

Skills: Screening Assessment, Patient Follow-up, Referral Coordination, Vital Signs Intake, Care Management Documentation, Appointment Coordination, Health Education, Community Resource Connection

• Participates as a member of the multi-disciplinary team and assists with the coordination of care including medical and social service needs and goals.
• Completes face-to-face visits which include evaluation regarding care plan progress and communicating results/coordinating next steps with the care manager.
• Assists with the implementation of interventions under the supervision of an appropriately licensed individual.
• Monitor ongoing needs of the patients/families to remove barriers, and ensure efficient and effective access to care and resources.
• Provides self-management support by helping patients/families to problem-solve and manage chronic medical or psychosocial needs.
• Accurately schedules appointments for members/families.
• Answer customer's questions regarding preparations for appointments, directions to clinics, and general hospital questions.
• Completes required documentation linked to the plan of care accurately and promptly.
• Provides updates to members/family regarding patient condition and progress, information is linked to the plan of care
• Refers parents to appropriate resources for information to answer questions and address needs.
• Consults with care team members to address complex issues.
• Supports population outreach to identify population(s) at risk and assist with closing such population gaps.
• Refer to other care team members as patient situation warrants and provide data and insights to the specific member needs
• Assist local health department with contact tracing

Skills: Care Coordination, Face-to-Face Visits, Intervention Implementation, Patient Support, Appointment Scheduling, Documentation, Resource Referral, Population Outreach

• Provides peer mentoring support, information, and guidance relevant to consumer needs (social skills, substance use recovery supports, primary care, training, etc.)
• Collaborates with behavior health, primary care, dental, and other UCFS services and clients to determine care plans related to basic needs, legal, medical, and insurance.
• Assists clients in meeting basic needs via case management, skill building, and coaching.
• Establish and facilitate a communication plan, timeline and follow-up
• Maintain familiarity with community resources and collaborate with state and local agencies and other community-based supports 
• Assists clients with access to program services, and area resources.
• Participates in Case Reviews and supervision
• Perform related administrative duties, including documentation of case management activities and any other record-keeping and administrative tasks required for reporting purposes.
• Develop a client-centered care plan that supports client empowerment and improvement of overall health status
• Attends all regularly scheduled team meetings and training
• Organizes and implements activities inclusive of awareness events, speaking engagements, and dissemination of written materials.
• Assist in planning for community outreach efforts with specific target groups
• Attend all training sessions before community outreach efforts
• Work effectively with project team and staff – flexibility, patience, accountability, and dependable

Skills: Peer Mentoring, Care Plan Collaboration, Case Management, Community Resource Coordination, Client Access Support, Documentation, Outreach Planning, Team Collaboration

• Identify the Native Americans in an assigned service area and inform them of Northern Valley Indian Health Services.
• Participate in the overall Community Health Program under the direction and guidance of the Community Health/Outreach Director.
• Assisting clients in identifying service needs and appropriate resources.
• Completing documentation on each client contact accurately and promptly.
• Making appropriate in-house or out-of-agency referrals.
• Coordinating the multi-services a client may be receiving.
• Assisting eligible clients in securing available financial funds for medical payments.
• Providing health education, counseling, support, and services focused on general health maintenance and promotion.
• Actively network with a minimum of four (4) community agencies at least quarterly.
• Communicate essential client information to related Northern Valley Indian Health departments and service areas regularly.
• With Supervisor approval, provide transportation and/or delivery of medications/food in situations of urgent need when no other means is available and the consequences of not receiving such may have an immediate untoward effect.
• Provide 80 service contacts each month, through either home visits and/or clinic and community contacts.
• Plan and implement at least one community-based health education class per month.

Skills: Community Outreach, Client Needs Assessment, Referral Coordination, Documentation, Health Education, Networking, Service Coordination, Transportation Assistance

• Serve as the principal resource for HelpCare patients regarding social services available in the community.
• Facilitate access to social service programs, health insurance options, and related community resources for patients.
• Advocate for patients and provide social support to decrease any barriers to successful self-management of health conditions and social determinants of health.
• Coordinate health education and provide referrals to appropriate educational resources/services.
• Follow-up with patients regarding care plans/action plans and address any barriers to successful implementation of those plans.
• Alongside the patient care coordinator, support the facilitation of formal patient referrals to specialty health services.
• Assist in developing, implementing, and maintaining a method of tracking services provided to illustrate measures of success.
• Utilize Electronic Health Record (EHR) for tracking patient interactions.
• Provide culturally sensitive care when working with volunteers and patients.
• Maintain communication with volunteer and paid staff.
• Carry an active caseload of 10 clients needing intensive case management/support.
• Become a Certified Child Passenger Safety Seat Tech within one year of hire
• Works collaboratively with the Care Team to optimize communication, coordinate needed services, and meet the needs of the patient

Skills: Social Services Coordination, Patient Advocacy, Health Education, Care Plan Follow-up, Referral Management, EHR Documentation, Cultural Sensitivity, Case Management

• Schedule and complete initial assessment, care plan, and follow-up phone calls for enrolled patients within specified timeframes.
• Work with participants to set goals around healthy eating and physical activities and motivate them to achieve those goals.
• Teach es key educational messages in person and over the phone.
• Document all activities in the study database.
• Reinforce educational messages regarding weight management by linking clients with supportive community services and programs.
• Record and monitor the participants' progress toward goals within specific timeframes.
• Texts participants weekly and follows up with them regarding their goals.
• Assist participants with making follow-up appointments for the health coaching sessions.
• Demonstrates sensitivity and respect for the culture of the participant.
• Provide general administrative duties including making follow-up appointments for participants, making reminder phone calls, and maintaining contacts and study database.
• Participates in activities related to addressing the social determinants of patient and community health such as assessing community strengths, advocating for the needs of individuals and families, and assisting with community organizing.
• Maintains confidentiality and is compliant with HIPAA

Skills: Assessment & Care Planning, Goal Setting, Educational Messaging, Activity Documentation, Progress Monitoring, Appointment Scheduling, Cultural Sensitivity, Social Determinants Advocacy

• Develop a treatment plan that helps a patient learn skill sets needed for independent living.
• Assess a patient's current condition and level of social functionality.
• Utilize medication and individual or group counseling, and they may assist with job training, housing needs, and family support issues.
• Monitor patients' progress, help them achieve their social integration goals, and intervene in crises.
• Assists Primary Care Team with identification of supportive services and resources available to their patients to meet specific needs.
• Connects patients with supportive services and resources that are critical to their overall health and wellness.
• Works with the Primary Care Team to provide Care Management and Care Coordination including engaging families, providing home visits, addressing basic needs, and health coaching.
• Assist with Care Management for Complex Care Patients including supporting hospital transition, barrier reduction, health coaching, and system coordination.
• Provides health coaching and health promotion for a diverse patient panel.
• Adheres to all SHHC policies and procedures
• Promptly, and consistently documents all patient interactions in Electronic Health Record.
• Participates in the daily team huddle and call patients in advance of visit with patient-specific reminders
• Work collaboratively and effectively within a team

Skills: Treatment Planning, Condition Assessment, Supportive Services Connection, Progress Monitoring, Care Management, Health Coaching, EHR Documentation, Team Collaboration

• Conduct outreach to identify high-need women and infants from events at community venues, schools, hospitals, clinics, churches, shelters, substance abuse treatment clinics, emergency rooms, etc.
• Facilitate educational presentations to participants, providers, and others regarding the MIH program and a variety of health topics using an approved curriculum.
• Enter client data and services provided into the database monthly.
• Conduct initial intake and/or assessment of participants and family situations and needs, and periodic re-assessments.
• Manage a small caseload of clients for case management support.
• Assist participants in attaining their goals by identifying and locating community resources for participants and by making referrals to appropriate services.
• Work with participants to overcome barriers/goals, and assist participants in advocating for themselves and in moving toward self-sufficiency.
• Act as liaison and advocate for participants with referral sources regarding participant’s progress related to their education, healthcare, housing issues, etc.
• Provide all required data and narrative information for weekly/monthly/quarterly/annual reports promptly.
• Maintain professional relationships with clients and client confidentiality.
• Work with other team members to accomplish program objectives.
• Continuous learning in both personal and professional development.
• Consistent review, comprehension and reply of company email and related correspondence.

Skills: Outreach, Educational Presentations, Data Entry, Intake Assessment, Case Management, Community Resource Referral, Participant Advocacy, Confidentiality Maintenance

• A willingness to work every other weekend
• Ability to pass or satisfy a Criminal Background screening upon hire
• Ability to satisfy a reference check
• A passion for making a difference in your community
• Good computer and data entry skills
• A good knowledge of prevention and environmental strategies
• Good facilitation skills, health coaching, and training/ability to teach
• Good health promotion education and advocacy skills
• Excellent data-gathering skills
• Good organizational and service coordination skills

Qualifications: BA in Public Health with 2 years of Experience 

• Post-hiring completion of agency OJT and CHW certification
• Excellent interpersonal skills, cultural competence /ability to work effectively with youth and adults
• Fully bilingual in English/Creole or Tri-lingual English/Creole/Spanish
• Excellent knowledge of HIV health issues and conditions
• Good communication and listening skills
• Strongly embrace and personify the mission of Alivio Medical Center
• Manage time, set priorities, work independently and have an effect on a team.
• An understanding and knowledge of Health Care Systems.
• Strong knowledge and experience in local, state, and federal Health Care Programs and services.
• Strong communication and organizational skills
• Highly motivated, self-initiated, and flexible.

Qualifications: BA in Community Health with 3 years of Experience 

• Completion of/working towards Community Health Worker (CHW) program and/or certification program and relevant work experience
• Extensive experience in a Human Services-related field may be considered instead of education.
• Experience as a Community Health Worker in a similar position in a healthcare environment
• Experience with care coordination and/or case/care management
• Ability to work and collaborate effectively with team members and leadership
• Excellent time management and organizational skills
• Self-motivated and able to work independently and set priorities
• Experience with Motivational Interviewing and community-based visits
• Understanding of the managed care environment with a focus on the Medicaid population
• Knowledge of welfare reform, homelessness, and community resources to address basic needs such as housing, food, transportation, clothing

Qualifications: BA in Psychology with 5 years of Experience

• Current Community Health Worker Certification by the State of Oregon within 3 months of hire
• Credible experience in project management
• Experience with healthcare and/or helping professions
• Knowledge of barriers encountered by low-income and culturally diverse families
• Comfortable communicating with clinical professionals, e.g., nurses, physicians, social workers
• Excellent computer skills, including proficiency in typing
• Microsoft Office suites and internet navigation.
• Exhibits professionalism, courtesy, and excellent customer service while interacting with patients, guests, and coworkers.
• Maintains patient confidentiality.
• Demonstrates ethical behavior inspires trust and exhibits honesty and integrity in the scope of daily activities.
• Proficient PC skills

Qualifications: BA in Social Work with 2 years of Experience

• Meaningful experience with community organizations, verified by personal or professional reference with personal knowledge of this fact.
• Personal knowledge of a neighborhood served by the MedStar Health community, preferably with current or recent residency in the stated community.
• Ability to comprehend and follow policies and procedures.
• A problem-solving orientation and a flexible and positive attitude
• Experience in healthcare, community-based, or social work environment
• Experience utilizing electronic medical record systems
• Knowledge of community resources and resource navigation
• Experience working on a multidisciplinary team
• Fluency in language that is commonly spoken in the community
• Most often this will include Bilingual English/Spanish
• Experience and demonstrated ability in providing direct services to Indigenous families.
• Proven ability to navigate a PC to open applications, send emails and conduct data entry

Qualifications: BA in Health Education with 3 years of Experience

• Excellent interpersonal skills, written and verbal communication skills
• Proficiency with Microsoft Office applications (including Microsoft Outlook, Word, Excel, PowerPoint, Access, and Visio).
• Attention to detail required, ability to troubleshoot or anticipate change desirable.
• Understanding of, and competence in, a highly professional realm requiring diplomatic communications with internal and external groups, with effective fielding of inquiries and professional representation of the program.
• Works well independently with minimal supervision and is expected to use initiative 
• Sound judgment in carrying out responsibilities within the framework of the department procedures.
• Ability to work evenings and weekends
• Self-motivated team player, with demonstrated ability to work independently with minimal supervision.
• Diplomacy and understanding of political sensitivities.
• Tactful approach in handling confidential and sensitive information and a high sense of responsibility and discretion.
• Demonstrated understanding of medical terminology.
• Knowledge of health care and social practices in Indigenous communities.

Qualifications: BA in Psychology with 2 years of Experience 

• Familiarity and/or experience with the Indian Health Service (CHSDA) and government-sponsored health care grants/initiatives for Indigenous communities.
• Experience in advocacy, outreach, coordination, and collaboration with Indigenous communities and healthcare settings.
• Established Indigenous/tribal community relationships.
• Familiarity with approaches to medical research involving Indigenous/tribal communities.
• Previous experience in tobacco education or cessation services.
• Social Worker, Medical Assistant, Engagement Specialist, or Community Health Worker Certification
• Equivalent work experience and education will be considered instead of a certification.
• Experience in the healthcare industry navigating relationships around providers, patients, community resources, and insurance networks
• Knows and understands specific health issues and understanding of health care/social service system
• Advanced computer skills, effective oral and written communication skills
• Ability to perform complex and diverse administrative duties that involve the application of procedures, independent analysis, interpretation of data and demonstrated appropriate judgment

Qualifications: BA in Social Work with 4 years of Experience 

• Experience working with clients in a community-based setting.
• Life experiences reflective of the community/target population served.
• Reliable transportation to travel to designated community locations.
• Ability to work with diverse client populations, community organizations, as well as staff at all levels.
• Ability to work independently and/or collaboratively within a team from general instruction
• Excellent verbal and written communication skills.
• Outstanding interpersonal, administrative, and organizational skills.
• Highly skilled in the use of personal computers, including Microsoft Office applications.
• Demonstrates commitment to the Partners-in-Caring process by integrating our culture into all internal and external customer interactions
• Experience with outbound calls to members, Physicians, Pharmacies, Providers, or similar medical facilities

Qualifications: BA in Human Services with 3 years of Experience 

• Prior experience as an outreach worker 
• Previous experience as a community health worker
• Previous experience conducting chronic disease education classes
• Previous experience conducting home and/or clinic visits with patients and their primary care providers
• Preferably from or know the community where the health facility is located
• Ability to communicate in the client/patient’s language and culturally sensitive
• Fluency reading/speaking in Afrikaans
• Long- term Resident of community served by CHC, with strong knowledge of the resources in that community.
• Excellent oral and written communication skills.
• Ability to carry out written and oral instructions
• Demonstrated experience in the area of obtaining community resources/advocating on behalf of the patient.
• Comfortable with computer data entry, able and willing to work full-time

Qualifications: BA in Community Health with 2 years of Experienc

• Licensed Practical Nurse (LPN), Certified Nursing Assistant/Home Health Aide, Certified Medical Assistant
• Have CHW Accreditation
• Experience working in Managed Care, Behavioral Health, and Substance Abuse
• Knowledge of TX Medicaid plans
• Familiarity with the resources available within the community
• Demonstrated ability to create, copy, edit, send & save utilizing Microsoft Word, Microsoft Excel & Microsoft Outlook
• Experience in community outreach, education advocacy work
• Bilingual in English and Spanish
• Self-starter with excellent communication skills.
• Ability to work well as a member of a team
• Interest in addressing mental healthcare disparities
• Willingness to learn new technology, attention to detail

Qualifications: BA in Health Education with 3 years of Experience