Community Health Worker/Navigator (52012)

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.

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.