Job Summary

The Community Health Worker is responsible for the coordination with primary care and behavioral health to deliver comprehensive services to patients and families throughout the continuum of care.

Qualifications

Associate degree in a human service-related field or equivalent work experience.  Bachelors preferred.  Mental illness or addiction experience helpful.  Bilingual/bicultural in Spanish strongly preferred.

Representative Job Duties

Coordination and facilitation of patient care across the continuum of care:

• Proactively contacts patients with due/overdue appointments, due/overdue tests, immunizations or screenings, or unmet
• Outreach to high-risk patients
• Identifies patients with barriers to referrals/transition and help patients address
• Works collaboratively with the care team to improve and ensure quality/timely care for high-risk patients
• Initiates and maintains trusting relationships with children and families
• Conduct home visits and site visits of community partners

Patient advocate/ liaison:

• Serves as point of contact for
• Identifies and establishes relationships with community resources, links patients with community Works collaboratively with school systems, early intervention specialists and assists in developing and increasing community collaboration and advocacy.
• Assists patients in problem solving potential issues related to referrals
• Assists patient in utilizing transportation resources to attend medical
• Works with the Enroller to help patients with obtaining health insurance

Patient support/transition of care:

• Track and support identified high risk patients when they obtain services outside of practice like emergency room, or other health care
• Assists with follow up of emergency room discharges by telephone call within 48 hours for identified high risk
• Works with the Provider team to facilitate prompt (48 hours) follow-up for identified high risk hospitalized
• Ensure accurate and timely documentation in Electronic Health

Promotion of patient health behaviors changes:

• Follows up with patient to ensure appropriate intervals between office
• Ensure that the patient and family understand the care plan and associated instructions as per
• All outreach activities are recorded in the appropriate template at the time of contact in respective patients’

Quality improvement and performance measurement:

• Generate reports as required
• Outreaches to patients on registries and schedules appointments accordingly.
• Assist in data collection and generation of patient registry reports.
• Participate in Performance Improvement/ Continuous Quality Improvement activities as

Other Educational/Technical Assistance Duties

• As requested, attend trainings in other subject areas and report and/or provide training to SBCHC staff (and others).
• As requested, attend community and health fairs representing SBCHC’s interest
• Provide technical assistance to other SBCHC committees and assist as appropriate in the development of programs and

Functions as member of the primary care team

• Participates in development of patient care plans with care team
• Meets with care team on a regular basis

Competitive benefits package.

Apply Now

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