Community Health Worker

Job Summary

Under the direction of the Director of Quality Improvement, the Community Health Worker will proactively manage health center populations with Hypertension and serve as the primary Technical Assistance person for the distribution, teaching, and troubleshooting usage of new remote monitoring EHR-integrated Blood Pressure devices. The CHW will outreach patients with Hypertension in need of preventative services to ensure continuity of care through a team-based, patient centered medical home approach. The CHW will also outreach to special populations who are eligible but still in need of the COVID-19 Vaccine, who may be experiencing vaccine hesitancy or may struggle to use online appointment request processes. The CHW will ensure routine screenings are up to date for social and mental health needs (SDOH, depression, substance use), and connect patients in need of additional supports who are ready to engage with Behavioral Health, Social Services, and community resources. The CHW will schedule appointments, enroll patients in the Patient Portal, and document patient outreach in the EHR.

Qualifications

• Community Health Worker certification strongly preferred
• Bachelor’s degree strongly preferred
• Knowledge of Microsoft Excel required
• Experience working in healthcare setting with patient-focused experience preferred
• Experience in healthcare quality and population-based clinical quality initiatives preferred
• Bilingual in Spanish or Albanian preferred

Representative Job Duties

Hypertension Outreach and Engagement

• Utilizes the EHR and Azara DRVS to identify patients overdue for Hypertension care with their Primary Care team, outreaches patients, and schedules appointments as needed.
• Organizes and analyzes patient lists to prioritize outreach and data entry.
• Collaborate with cross-functional teams (Population Health, Primary Care, Behavioral Health, Care Management) to provide quality care to patients with Hypertension who have other care gaps.
• Performs chart review in the EHR prior to outreach to verify care gaps for which a patient is due.
• Identify patients with multiple elevated BPs and facilitate engagement with their PCP, BH provider, and/or Specialist, including scheduling appointments and messaging care teams as needed.
• Screen patients for social and financial health barriers, depression, and substance use by conducting standardized screenings over the phone or in person.
• Meet with patients who would benefit from extra care coordination to engage with their care team.
• Help as needed with translation/completion of community resource forms and phone calls for patients with English language barriers.
• Works collaboratively with health center providers and staff to address patient care.
• Enrolls patients in the Patient Portal.
• Utilizes population health registries and the EHR to generate and deliver population health reminders (i.e., letters, telephone, patient portal messages, or CareMessage text messages).

Remote BP Device Technical Assistance

• As part of a HRSA grant initiative to enable home monitoring of blood pressure, helps distribute Bluetooth-enabled BP devices to eligible patients with Hypertension.
• Attends all HRSA grant-related training and technical assistance activities.
• Serves as the health center’s main point of contact for BP device patient teaching and technical troubleshooting, with support.
• Using an EHR report to track utilization of remote BP devices, identifies and outreaches patients who are not actively reporting BPs to assess for barriers and offer assistance with device utilization.
• Assists patients in using the Patient Portal to enable EHR-integration of their remote BP device.

COVID-19 Vaccine Outreach and Engagement

• Utilizes the EHR to identify special populations eligible to receive the COVID-19 vaccine who have not yet been scheduled for an appointment.
• Learns and deploys the population-focused materials created by the Massachusetts League’s COVID-19 vaccine engagement campaign, in which CHWs will learn about vaccine safety and development, strategies for targeting population-specific hesitancy, and gain knowledge about vaccine operations and administration.
• Makes calls to patients who need the COVID-19 vaccine, assess and try to mitigate barriers (e.g., arrange for transportation or language assistance, book appt while on the phone with the patient to overcome technology barriers).
• Offers therapeutic listening, empathy, and accurate information on the COVID-19 vaccine to those experiencing vaccine hesitancy.
• Verifies and updates demographic data in the Electronic Health Record (EHR).
• Assists primary care teams by reconciling state immunization registry (MIIS) with local chart to pull in externally administered COVID-19 Vaccines.
• Enrolls patients in the patient portal.
• Communicates effectively, efficiently, and professionally over the phone with patients.

Quality Improvement

• Participates as a QI Champion in Hypertension and COVID-19 Vaccine QI initiatives
• Reports data inconsistencies to the QI/CI (Clinical Informatics) Team in a timely manner.
• Monitors progress on quality measures related to Hypertension and COVID-19 Vaccination.
• Improves patient care and data quality by entering external results in structured data fields in the EHR to record clinically relevant patient care performed outside of the health center.
• Actively works to identify opportunities for improvement in workflows to improve population health and provides constructive ideas, suggestions, and feedback in a positive manner.
• Coordinates with Director of Quality Improvement and the QI/CI Team to promote quality throughout the health center and troubleshoot areas of concern.

Health Center Participation

• Provides consistent, reliable, and excellent customer service internally and externally.
• Contributes to the team effort by supporting all staff members and maintaining an open and positive attitude.
• Adheres to all health center and departmental policies and procedures.
• Attends all required meetings.
• Participates in additional quality assessment and improvement activities as requested.

Competitive benefits package.

Apply Now

Please submit cover letter and resume to hr@sbchc.org.