The Community Health Worker - Case Management builds trusting and supportive relationships in order to coordinate care for patients with complex chronic conditions. This position facilitates patient access to medical, behavioral, and social services by playing a role as liaison or intermediary with medical and social agencies. Collaborates with the member and integrated care team to ensure continuity and culturally competent integrated community-based care.
Duties and Responsibilities:
Responsibilities may include, but are not limited to, the following:
- Must be comfortable completing visits independently or as a care team in members’ homes. Completes home visits to perform assessments on member's basic social and human needs.
- Dependability and time flexibility, when necessary; commits to working across all interdisciplinary teams, educate members on alternative to Emergency Department (ED) for non-emergent care; assist, train, and coach members to obtain, schedule and reschedule health care appointments; explore transportation options and provide tips and techniques to ensure follow-up with service providers.
- Complete hospital or skilled nursing facility visits to support transitional care management process for community resource needs.
- Educate and help to keep members in compliance with their care plan goals and better utilizers of the health care system
- Coordinate the provision of services/care to meet the member's social and health needs. Aids members, families, and caregivers in accessing basic resources such as food and housing
- Collaborate with other health professionals, including contacting primary care provider offices, care management staff and community social service agencies on behalf of the member.
- Prepare and participate in team meetings
- Serve as patients' key contact with health care team and facilitates interpretation abilities when applicable.
- Maintain appropriate written and verbal communication and documents member encounters and updates the documentation within established time frames
- Maintain patient confidentiality within legal and regulatory parameters
- Travel throughout Rhode Island is required for multiple home visits daily.
- Other duties as assigned
- Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agent