Job Title: Community Health Worker
Department/Program: Population Health
Reports To: Manager, Care Management
Created/Revised: March, 2021
Health Federation of Philadelphia’s care management program is aimed at reducing health inequities, addressing social determinants of health, and improving health outcomes for low-income patients struggling with chronic physical and mental health conditions. We are seeking an experienced and tech-savvy Community Health Worker who is familiar with the pace of, and populations served by, community-based health care providers in Philadelphia.
This position will be part of a team of four, including the Team Manager (a Social Worker), a Nurse Care Manager and another Community Health Worker who work with six community health centers and a Medicaid Managed Care Organization (MCO) to achieve improved outcomes for health center patients enrolled with the MCO and attributed to one of the health centers. The Team works to assess needs of identified patients at high risk of poor health outcomes, and to engage these individuals in primary care and other services, with the goals of improving health status and reducing hospitalizations, as well as to address quality metrics and “care gaps”. The Care Management Team engages patients who are not receiving regular care at their assigned primary care location and follows-up with individuals with recent hospital contact (inpatient and/or Emergency Department).
This position will eventually be a mix of telephonic and face-to-face patient contact; outreaches may take place at local hospitals, community health centers, and patient homes. Currently, most to all patient contact is telephonic due to COVID-19. This role includes using a variety of software systems daily, including Google suite applications (Sheets, Forms, Docs), population health management tools, and various systems to remote into secure environments.
- Engaging patients to review medication adherence, regular health monitoring, addressing social and medical barriers to good health, and reinforcing self-management for positive health outcomes.
- Connect and guide patients to community resources and assist in navigating the healthcare system.
- Collaborate in the development and implementation of workflow, processes, and ancillary materials for patients attributed to health centers and designated as “high risk” or who have experienced care transitions.
- Effectively engage identified individuals in Care Management services, using telephonic and in-person outreach.
- Formulate and implement a care management plan that is mutually agreed upon by the health care team and the patient/family.
- Perform follow up calls for patients recently discharged from acute hospitalizations and who are considered to be high risk for readmission. As needed, perform hospital visits and/or home visits.
- Collaborate with health center based providers, inpatient facilities, the Medicaid MCO, and skilled nursing facilities to manage care across the healthcare continuum and optimize clinical and financial outcomes.
- Maintain accurate and timely documentation.
- Maintain constant communication with health center care teams to insure that all members of the patients’ healthcare team are informed and duplication of effort is avoided.
- Efficiently navigate Google suites and remote environments to review and analyze data, and document and respond to daily tasks.
H.S. Diploma/GED required
- Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.
- Demonstrates ability to work autonomously and be directly accountable for practice.
- Demonstrates ability to function effectively in a fluid, dynamic and rapidly changing environment.
- Demonstrates leadership qualities including time management, verbal and written communication skills, listening skills, problem solving, critical thinking, analysis skills and decision-making, priority setting, work delegation, and work organization.
- Demonstrates ability to develop positive, longitudinal relationships and set appropriate boundaries with patients/families.
- Demonstrates good written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills.
- Adept with technology and data, including electronic health records, payer portals, Microsoft office, and Google apps.
- Understands the workflows and challenges of busy primary care offices.
- Ability to work autonomously in the community, while maintaining professional boundaries and productivity.
- Demonstrates technical proficiency by operating general office equipment as necessary to complete essential functions, including using spreadsheets, word processing, remote desktops, external software, email, internet, and other computer programs.
- Community health center and/or Medicaid program experience a plus.
- Good knowledge of Philadelphia neighborhoods and the resources of these communities.
Position Type and Work Schedule
This is a full-time, non-exempt position.
Standard office setting, plus regularly scheduled meetings, trainings, etc. with participating health centers, occasional home or hospital visits.
Able to sit and work at a computer keyboard for extended periods of time. Able to lift and move up to 15 pounds.
Must be able to get around effectively within Philadelphia and surrounding counties, either on public transportation and/or in own vehicle. Limited travel beyond surrounding counties will be required, as well.
The Health Federation reserves the right to modify, interpret, or apply this job description in any way the Company desires. The above statements are intended to describe the general nature and level of work being performed by an employee assigned to this position. This job description in no way implies that these are the only duties, including essential duties, responsibilities and/or skills to be performed by the employee occupying this position. This job description is not an employment contract, implied, or otherwise. The employment relationship remains “at will.” The aforementioned job requirements are subject to change to reasonably accommodate qualified disabled individuals.
Equal Opportunity Employer
The mission of the Health Federation of Philadelphia is to improve access to and quality of health and human services for underserved and vulnerable populations. Health equity is at the heart of all our work. We believe in and are firmly committed to equal employment opportunity for employees and applicants. We do not discriminate on the basis of race, color, national or ethnic origin, ancestry, age, religion, disability, sex or
gender, gender identity and/or expression, sexual orientation, military or veteran status. This commitment applies to all aspects of the Health Federation of Philadelphia’s employment practices, including recruiting, hiring, training, and promotion.