Community Health Worker (43628)

Health@Home is an innovative home-based primary care program developed in partnership with the Neighborhood Health Plan of Rhode Island and members' primary care teams. The program delivers evidence-based care that is both high-quality and cost-effective, aiming to enhance the quality of life for Rhode Island members.

The Community Health Worker builds trusting, supportive relationships with patients to coordinate care for individuals with complex chronic conditions. This role provides home-based primary care support for Neighborhood Health Plan members with significant medical and social needs. Working as part of an interdisciplinary care team, including Nurse Practitioners and Community Health Workers, the Community Health Worker helps deliver personalized, community-based care focused on improving health outcomes, strengthening community well-being, and reducing healthcare costs.

The Community Health Worker facilitates access to medical, behavioral, and social services by serving as a liaison between patients, healthcare providers, and community-based organizations. In close collaboration with the Nurse Practitioner and broader care team, this role supports continuity of care and the delivery of culturally responsive, integrated community-based services.

Duties and Responsibilities:

Responsibilities include, but are not limited to, the following:

• Must be comfortable completing visits independently and as team in patients' homes. Perform 4-5 home visits per day to follow up on member's needs, assessments on patient's basic social and human needs.
• Educate patients on alternative to emergency room for non-emergent care; assist, train and coach patients to obtain, schedule and reschedule health care appointments; explore transportation options and provide tips and techniques to ensure follow-up with service providers. Makes home visits to patients to perform assessments on patient's basic social and human needs
• Provides direct care in patients' homes related to vitals, lab testing and phlebotomy, if applicable. Communicates findings with providers and documents in EMR.
• Serves as patients' key contact with health care team and facilitates interpretation abilities when applicable. Support transitional care management process
• Identifies potential medical or behavioral health concerns and collaborates nurse practitioner (NP) and/or supervisor and other healthcare providers.
• In collaboration with care team coordinates the provision of services/care to meet the patient's social and health needs. Provides assistance to patients, families and caregivers to access basic resources such as food and housing
• Collaborates with other health professionals, including contacting primary care provider offices, care management staff and community social service agencies on behalf of the patient
• Effectively collaborates with Management, Community Health Coordinators and Nurse Practitioners and fosters collaborative teamwork to ensure comprehensive, patient centered care.
• Prepares and participates in team meetings
• Maintains appropriate written and oral communication and documents patient encounters and updates the EMR within established time frames
• Oversight for supporting departmental HEDIS Measures
• Cross trains with Community Health Coordinator role.
• Maintains patient confidentiality within legal and regulatory parameters
• Other duties as assigned
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agent.