Care Transitions Community Health Worker

Job Description

Job Description

Organizational Description

The Community Health Center Network (CHCN), sister organization to the Alameda Health Consortium, is made up of the eight federally qualified community health centers in Alameda County. CHCN functions as the managed care MSO for our health centers, contracting with Alameda Alliance for Health. To help our health centers meet their missions of providing the best possible care to their communities, we also provide a broad range of training, technical assistance, quality improvement, information technology, and data analytic services.

Position Title: Care Transitions Community Health Worker (CHW)

Department: Healthcare Services Division

Reports To: Care Transition Nurse Supervisor

Classification: Non-Exempt

Status: Full-Time Regular (Onsite)

Salary: $25.45/hour to $30.65/hour

POSITION SUMMARY

The Community Health Worker (CHW) will provide in-person support to Community Health Center Network (CHCN) members who present at Sutter Health System hospitals, focusing on improving health outcomes by connecting patients to their primary care providers and reducing unnecessary acute care utilization. This role acts as a vital liaison between Sutter Health care teams and CHCN health centers, ensuring seamless care coordination for patients.

Key Responsibilities:

• ED Case Management Collaboration: Work closely with Emergency Department (ED) case management teams to review CHCN patients and determine whether outpatient care would be a more appropriate option for their needs, aiming to reduce unnecessary ED visits.
• Follow-Up Scheduling: Engage with CHCN patients in the ED, assess their care needs, and schedule follow-up appointments with their primary care providers to ensure continuity of care.
• Medication and Referral Coordination: Facilitate communication with CHCN providers to address any medication refills or non-urgent referrals, ensuring patients do not need to return to the ED for these services.
• Hospital Discharge Support: Assist high-risk CHCN patients who are hospitalized at Sutter hospitals, ensuring they are scheduled for follow-up with the Advanced Care Transitions (ACT) Team to support their post-discharge care.
• Care Handoff: Collaborate with inpatient care teams to transfer key information about high-risk patients to ACT providers, ensuring a smooth transition from hospital care to ongoing management in the community health setting.

Qualifications:

• Strong Communication Skills: Must possess excellent verbal and interpersonal communication skills to build positive relationships with hospital staff and community health teams. The CHW will represent CHCN within the hospital setting and must be an effective liaison.
• In-Person Role: This position requires regular in-person presence at the Sutter Health System hospital Emergency Department (ED), and the CHW must have reliable transportation to and from the assigned hospital site.

Desired Attributes:

• Ability to work collaboratively in a fast-paced, dynamic environment.
• Compassionate and patient-centered approach to care coordination.
• Strong organizational and time management skills.

HIPAA Designated Access

“For the purposes of the job duties of this position, the person in this position requires access only to the following HIPAA protected information data sets.”

1. MSO Membership

2. MSO Claims

3. MSO Referral/Auth.

4. MSO Capitation

5. Data Warehouse

6. Chart Audit/QI

7. Disease Registry

SUPERVISORY RESPONSIBILITIES

None

CERTIFICATES AND/OR LICENSES

None

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit and use hands to finger, handle, or feel. The employee is frequently required to talk or hear. The employee is frequently required to stand; walk; reach with hands and arms and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus.

WORKING CONDITIONS AND ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly exposed to an inside/outside environment.

The Community Health Center Network is an Equal Opportunity Employer.