• As an integral part of an Interprofessional Care Team and based on the fluctuating needs of a defined panel of members, the Community Health Worker will engage in regular assessments pertaining to Social Determinants of Health, outreach members telephonically at regularly scheduled intervals, and conduct urgent follow-ups to ensure that members' Plan of Care is fully comprehensive and addresses significant medical, behavioral, and social needs. The CHW works toward the promotion, prevention, and reduction of health risks. The CHW will support the health education needs of the member in collaboration with the Interprofessional Care Team and PCP.

• The Community Health Worker will assess health risks and identify gaps pertaining to SDOH which create barriers to member's care and contribute to unmet needs. The Community Health Worker will coordinate with the member's PCP (Primary Care Provider), as well as CCA's interprofessional clinical care team to identify areas of opportunity, as well as defined resources, and will work in coordination with the team to implement the care plan. In collaboration with the member, the CHW will take ownership of SDOH goals in the member's care plan and will provide input and support for key care management or coordination decisions.

The CCA CHW:

• Facilitates and/or delivers preventative care and health coaching to members according to guidelines set by CCA Clinical Leadership
• Identifies and initiates a member agreed-upon plan to resolve areas of opportunity to meet quality metrics
• Assesses members' social determinants of health (SDOH), and provides support, further evaluation, or coaching as needed to support members in prioritizing their needs and goals
• Supports efforts to decrease hospital readmissions and high emergency department use
• Provides Diabetes Basics or other health coaching/education to members, as appropriate to support members' goals and care plan
• Supports health education to members on key quality metrics, including preventive care/screenings
• Participates in Root Cause Analysis (RCA) as needed
• Assists members in obtaining or stabilizing housing, finances, food, utilities, educational/vocational opportunities, and community supports
• Liaises with community-based PCPs/ Specialists as needed.
• Engages with community agencies and service providers to build relationships to support membership
• Uses recovery strategies such as motivational interviewing, harm reduction, positive behavioral support techniques, limit setting, and strengths-based approaches to support members in attaining stated goals
• Provides 1:1 health education to members regarding chronic disease self-management to prevent and manage health conditions and encourage development of healthy behaviors/habits
• Provides consultation and support to other members of CCA Care Team
• Maintains appropriate written and oral communication on a timely basis, completing documentation within 24 hours of activity, and returning non-urgent calls within 48 hours
• Actively participates in the evaluation of own performance and progress
• Participates in ongoing education and training to improve skills and role-specific certifications or specialization
• Participates in CCA quality improvement efforts
• Assists CCA management and leadership with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects
• Participates in committees and workgroups that promote clinical excellence and help to advance CCA's mission and business objectives
• Provides clinical care to members via telehealth technologies (i.e., video, chat) for clinically appropriate clinical care and care management services
• Other duties as assigned

• Minimum Education Required - Associates Degree

• Bachelor's Degree
  Master's Degree
  CHW certification

• Experience with electronic medical record strongly preferred

• English