We’re unique. You should be, too.

We’re changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded Is your work ethic and ambition off the charts Do you inspire others with your kindness and joy

We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team.

The Community Health Worker, HCT is a vital HCT member, who will use a strong knowledge of the local community to help engage patients in our primary care model, deepening the patient relationship with us and the patient's understanding of their plan of care. The incumbent will facilitate visits with our physicians through video during these community visits. The Community Health Worker, HCT will also use telephonic outreach to ensure patients are doing well after hospital discharge and during other times of increased medical risk to the patients. The incumbent will work closely with our nurse care managers and social workers to support a multidisciplinary approach to meeting our most complex patients' medical and social needs. Additionally, the incumbent will also support the HCT with patient scheduling and other tasks as determined by the team leaders.

ESSENTIAL JOB DUTIES/RESPONSIBILITIES:

• Assists patients in their homes with telehealth visits with their Primary Care Physicians
• Works with patients assigned to us, but not actively engaged in care to link them to our physicians with the goal of full engagement in our model of care.
• Assesses patient need for transportation to and from the appointment and coordinates with centers to schedule or assist patients with their health plan transportation policy for specialty appointments outside our centers.
• Links patient and family with community resources when necessary, including assistance with patient and family on completion of a Medicaid Application and other application for programs for which they may be eligible.
• Performs discharge phone calls within 24-72 hours post discharge from inpatient setting. (Hospital, SNF, Long Term Acute Care Hospital (LTACH) using post discharge script explaining our services and obtaining consent for visits and upload to patient's chart.
• Communicates between patient and discharge champion in the center to assure patient has 4- day post discharge appointment to see their Primary Care Physician (PCP).
• Works collaboratively and effectively within the team of Community Nurse and Community Social Worker on their individual visit schedule, maintaining great communication with Nurse and Social Worker while maintaining their schedule and calendar.
• Coaches’ patients in effective management of their chronic health conditions and self-care
• Motivates patients to be active, engaged participants in their health.
• Continuously expands knowledge and understanding of community resources, services and programs provided; human relations and the procedures used in dealing with the public as part of a service or program; volunteer resources and the practices associated with using volunteers, operations, functions, policies, and procedures associated with the department or program area, procedures, and resources available to handle new, unusual, or different situations.
• Attends meeting and reports on patients as assigned.
• Performs other duties as assigned and modified at manager’s discretion.

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