Community Health Worker - Enhanced Care Management Care Coordinator

Community Health Worker / Enhanced Care Management (ECM) Care Coordinator plays a critical role in reaching out to the community providing education and assisting individuals and families in accessing health insurance healthcare services and other needed supports. In addition to promoting health literacy and selfsufficiency the ECM Care Coordinator is responsible for coordinating care for patients with complex medical behavioral and social needs addressing barriers to care and connecting patients to vital community resources.

A Community Health Worker (CHW) is a trusted member of and/or has a unique understanding of the community they serve. This relationship allows the CHW to act as a liaison between health and social services and the community improving the quality cultural competence and accessibility of service delivery. Through outreach care coordination informal counseling advocacy and education the CHW empowers individuals and builds community capacity to achieve better health outcomes. This role focuses on proactively engaging highrisk patients addressing social determinants of health and collaborating with interdisciplinary teams to deliver comprehensive patientcentered care.

Essential Duties and Responsibilities include the following:

Care Coordination and Individualized Planning

• Coordinate care for patients with complex needs ensuring access to a range of services and resources.
• Develop implement and monitor individualized care plans tailored to each patients unique needs and goals.
• Collaborate with interdisciplinary teams including primary care providers and behavioral health team members to provide comprehensive care.
• Act as a liaison between patients healthcare providers and community services to bridge gaps in care.

Advocacy and Resource Connection

• Advocate for patients to access necessary services such as housing food assistance transportation and mental health resources.
• Assist patients in navigating the healthcare system including followup care specialty appointments and referrals.
• Conduct outreach to locate and engage patients who are difficult to reach or at high risk for hospitalization.

Addressing Social Determinants of Health (SDOH)

• Assess and address social determinants of health that impact patients wellbeing including food insecurity homelessness or lack of access to transportation.
• Connect patients to appropriate community resources and social services to address nonmedical needs.

Education and Support

• Offer guidance and support on selfcare practices to improve patient outcomes.
• Provide social support by listening to patient and family concerns and helping develop problemsolving strategies.
• Support individualized goal setting using motivational interviewing and other patientcentered approaches.

Documentation and Compliance

• Maintain accurate and uptodate records of patient interactions care plans and referrals.
• Ensure timely documentation in the electronic health record (EHR) and prepare reports for internal tracking and compliance with external reporting requirements.

Crisis Response and Quality Improvement

• Respond to urgent situations such as potential hospitalizations emergency department visits or behavioral health crises to coordinate care and improve outcomes.
• Participate in quality improvement initiatives to enhance care coordination processes and patient satisfaction.
• Monitor patient satisfaction and identify areas for improvement within the care management program.

Collaboration and Best Practices

• Participate in regular interdisciplinary care team meetings to discuss patient progress barriers and opportunities for improvement.
• Provide input on care coordination best practices and refine care pathways based on patient needs.
• Conduct individual and other community outreach and educational sessions to inform current patients stakeholders and other community members in health care topics of interest including
• Other duties as assigned.

Education and Experience:

Community Health Worker certification is required. High school diploma or general education degree (GED); or oneyear related experience and/or training with additional years of experience preferred but not required; or equivalent combination of education and experience;

Qualifications:

To perform this job successfully an individual must be interested in fostering community members wellbeing demonstrated by experiences and/or education regarding helping people. The requirements below represent the required knowledge skill and/or ability. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

Language Skills:

Must be fully bilingual and biliterate (Spanish/English). Ability to read and interpret documents such as safety rules operating and maintenance instructions and procedure manuals. Ability to write routine reports and correspondence ability to speak effectively before groups of customers or employees of the organization. Must be able to communicate effectively with patients via telephone.

Preferred CHW Attributes:

Connected to the Community; Community member OR have a close understanding of the community they serve; Shared life experiences; Desire to help the community Persistent Creative and Resourceful; Determined; Imaginative; Ingenious; Mature; Courageous; Prudent; Wise; Empathetic Caring Compassionate kind gentle considerate sensitive openminded;

nonjudgmental honest respectful patient sincere candid polite courteous dependable responsible reliable selfdirected welcoming.

Other Qualifications:

Must be fully bilingual (Spanish/English) and able to work evenings and/or weekends if required.

This position is funded and its continuation is contingent upon the availability of funds. Candidates are encouraged to apply with an understanding of the grantfunded nature of the role.