Community Health Worker Job at Aledade, Inc.

Job Description

As a Community Health Worker, you will work closely with the physician organization, medical providers, primary care teams, and social services agencies to provide short-term care coordination related to Social Determinants of Health (SDOH) needs. Coordination to include linkage to community resources and support programs, assisting patients to improve their health and general well-being through education and provision of appropriate services.

Job Responsibility

Conducts outreach to targeted patient population to identify community resource needs
Conducts SDOH screenings on patients
Assists patients in identifying socio-economic issues that affect their overall health and in developing self-management plans and goals
Documents all patient encounters
completes and submits monthly reports
maintains comprehensive electronic patient files
Facilitates communication and coordinates services between providers and the patients, and tracks patient compliance with the care plan objectives
Provide appropriate billing code for services provided
Creates and maintains a comprehensive community resource database relevant to clinics’ patient populations
Participates in care team meetings and contributes to the patient plan of care

Requirements

High school diploma or GED
CHW certification or willingness to obtain upon hire
1 year experience relevant to position and responsibilities
Resident of Michigan or bordering state
Strong interpersonal and community skills and ability to work effectively with a diverse community
Knowledge of community resources and agencies, for example- knowledge of transportation and other barriers to care
Working knowledge of multi-system outreach programs related to health care delivery, clinical education, and health-related services
Ability to plan, implement, and evaluate individual patient care plans
Ability to communicate medical information to patients over the phone
Skill in use of personal computer and related software applications, including email and excel
Creative and analytical thinking

Nice to have

Knowledge of the PCMH and PCMH-Neighbor (PCMH-N) models of care
Experience with EHRs, disease registries, or other medical software
Billing and coding experience

What we offer

Flexible work schedules and the ability to work remotely are available for many roles
Health, dental and vision insurance paid up to 80% for employees, dependents and domestic partners
Robust time-off plan (21 days of PTO in your first year)
Two paid volunteer days and 11 paid holidays
12 weeks paid parental leave for all new parents
Six weeks paid sabbatical after six years of service
Educational Assistant Program and Clinical Employee Reimbursement Program
401(k) with up to 4% match
Stock options

Aledade, Inc. - All Job Offers