Medical Community Health Worker

Job Description

Medical Community Health Worker

Optimus Health Care is a Federally Qualified Health Care Center with sites operating in Bridgeport, Stamford and Stratford, CT. We are the largest provider of primary health care services in Fairfield County, proudly serving all patients regardless of their income, race, or insurance status. We are presently recruiting for a Medical Community Health Worker to join one of our Bridgeport, CT sites.

This position is 100% Grant Funded

POSITION SUMMARY

The Medical Community Health Worker (Med-CHW) will promote the PCMH+ ( patient centered medical home) model by being the liaison between medical, behavioral health, home and community. Placed primarily in an outpatient medical health setting and at various locations when required. Med-CHW will provide individualized comprehensive case management that supports, improves and maintains overall health and wellbeing of patients served. The Community Health Worker works closely with primary care, behavioral health, school social workers when applicable, social services agencies and other community partners to assist with coordination of care and services. Must be comfortable working with culturally diverse populations including various gender identities/sexual orientation. Highly personable, very organized, self-directed with reliable transportation. Must be open to working a flexible scheduled when needed, coupled with strong verbal and written communication, in addition to strong commitment to maintaining a high level of confidentiality.

ESSENTIAL FUNCTIONS & RESPONSIBILITIES

Care Coordination & Outreach
•    Facilitates access to community resources: housing, food, clothing, parenting classes, vocational services, educational resources, assist with completion of redetermination forms for social programs.
•    Assist with creating, assessing and re-evaluating patient-centered plans that include patient self-management goals.
•    Work with student/family in their homes, school, community, or clinic setting.
•    Motivates patients and their families/care givers to remain actively engaged in meeting measurable objectives.
•    CHW will coach patients and their families/care givers on proper use of the emergency room visits and offer alternative options.
•    For Med-CHW’s working with pediatrics, assistance will be provided to clinical and non-clinical providers to decrease or eliminate cultural and socio-economic barriers that hinder our patients’ overall Wellness.
•    Participate in community health initiatives, health fairs and other pertinent events.
•    Responsible for being present at required staff meetings.
•    Attend individual and group supervision with supervisor as required.
•    Performs other duties as assigned.

Documentation
•    Documents all patient encounters including phone calls and/or discussions with collateral agencies.
•    Ensure proper DAP (data/assessment/plan) format when documenting
•    Accountable to scan all required documentation into EHR: Releases, guardianship, health records, conservatorship, IEP or 504 plan if applicable.
•    Will maintain accurate up-to-date documentation in electronic health records (EHR)
•    Develop and update integrated care plan with multidisciplinary team
•    Complete screening tools (CAGE, PHQ9, health literacy, PRAPARE, etc…)
•    Encourage patients participation in wellness recovery action plan (W.R.A.P) when appropriate
•    Participates in peer review file audits
Collaboration and Advocacy
•    Present at all necessary clinical team planning meetings including medical and behavioral health
•    May provide support and advocacy during initial visit to assure behavioral health/medical needs and required referrals are being conveyed.
•    Help advocate for special accommodations in school, home, community and healthcare settings when needed.
•    Assist with transitioning youth to adult medical and/or behavioral health care
•    Identify gaps in health services and coordinate clinical care
•    Collaborate with school, community partners, home and healthcare providers to assist with achievement of established goals.
•    Attend relevant community meetings to build collaboration and cultivate relationships with community members.

ADDITIONAL GENERAL REQUIREMENTS

Professional, positive attitude, understanding of customer service principals, intuitiveness, trustworthiness, and excellent interpersonal skills to successfully accomplish tasks necessary to meet high standards of ethical and social responsibility required by this position. Knowledge of some medical terminology preferred. Ability to understand the needs of the community to be served. Must have knowledge of the various services available in the community. Ability and willingness to provide emotional support, encouragement and patient empowerment. Ability to type into an electronic health record.