Community Health Worker TMIN Southern… at Tufts Medicine · Tufts…

We are hiring for individual to support the Southern Region including Cape Cod.

Role is hybrid with limited travel in the above county.

Our Integrated Network brings together a diversity of experienced private practice and employed physicians as well as community and academic providers. While we are one unified network, we focus on different geographic regions, with local care teams convening to ensure healthy, happy neighborhoods throughout the greater Boston region.

Job Overview

This position delivers culturally-competent services to help patients navigate and access community services, other resources, and adopt healthy behaviors. Assists with care coordination tasks such as appointments and/or transportation (transporting patients is strictly prohibited), patient education and assistance with navigating physical and behavioral health systems, and facilitating communications with providers and other care team members. Helps patients’ self-management by evaluating their needs, assisting with plan development, and working towards patient-centered goals.

Job Description

Minimum Qualifications:

1. High school diploma or equivalent.

2. One (1) year of experience in healthcare related field such as hospital, home health provider, or community-based agency.

3. Valid, state-issued driver’s license and reliable transportation.

Preferred Qualifications:

1. Associate’s degree in Public Health, Healthcare, or other health science.

2. Three (3) years of experience in healthcare related field such as hospital, home health provider, or community-based agency.

3. Bilingual.

4. Experience working in a multi-cultural setting.

5. Experience working in a community-based setting.

Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.

1. Promotes, maintains, and improves the health of patients and their family through disease education and wellness as well as advocating for individuals with community health needs.

2. Meets patients in their homes and perform structured assessments that include goal setting and motivate patients to meet their health goals.

3. Establishes trusting relationships with patients and their families while providing general support and encouragement, providing social support and informal counseling using motivational interviewing and goal setting.

4. Assists patients with completing applications and registration forms, both financial and community-based resources, such as applications for Medical Assistance and SNAP (Supplemental Nutrition Assistance Program).

5. Refers to internal or external care management services when other issues are identified (i.e. food insecurity, domestic violence, etc.).

6. Provides ongoing follow-up with patients via phone calls, home visits and visits to other settings where patients are located.

7. Works closely with the medical provider to help ensure patients have comprehensive and coordinated care as well as work cooperatively with other clinical personnel assigned to the same patient as part of an Interdisciplinary Care Team.

8. Provides consistent communication to hospital care coordinators to update and evaluate patient/family status, ensuring that provided information, and reports clearly describe progress.

9. Reports high-risk problems including homelessness, substance abuse and food insecurity after assessment by a licensed social worker clinician.

10. Acts as a patient advocate and liaison between the patient/family and community service agencies.

11. Manages assigned caseload of patients and record patient information in the designated EMR (training provided) and other software no later than 48 hours after patient contact.

12. Maintains collaborative, team relationships with peers and colleagues in order to effectively contribute to the working group’s achievement of goals, and tactics to meet the overall organizational goals.

13. Acts as a patient advocate and liaison between internal and external providers, and community resources to integrate complex services and identify gaps and challenges in care and communication.

Physical Requirements:

1. Frequent sitting, standing, and walking.

2. Bending and frequent lifting of 30-35 lbs.

3. Moderate noise in work environment while performing tasks.

4. May be exposed to verbal or physical abuse from patients.

5. Requires manual dexterity using fine hand manipulation to operate computer keyboard, writing, and cutting.

6. Requires ability to hear, to write clearly, to read text and computer screen, and to verbally communicate in a clear and concise manner.

Skills & Abilities:

1. Lives in or familiarity with the target community and feels connected to that community.

2. Demonstrates ability to work well with people of various ages, backgrounds, ethnicities, cultures and life experiences.

3. Excellent interpersonal and communication skills telephonically as well as face-to-face.

4. Strong customer service skills.

5. Detail oriented, with strong organizational skills and multi-tasking abilities.

6. Ability to work independently with minimal supervision and as part of a team.

7. Knowledge of medical terminology.

8. Very strong working knowledge and proficiency with technology and business software (Microsoft Office).