Community Health Worker (Case Manager)

 Community Health Worker- Home Provider Program (Telecommute) 

• Assesses client and home environment to identify physical, social, emotional and knowledge barriers to optimal client care. Identified pertinent information and communicates to care team.


• Facilitates client’s health through advocacy, support with understanding and use of benefits, assistance in scheduling appointments, development of a support system, and reinforcement of self management and organizational tools.


• Supports client well-being by using strong observation and communication skills to coordinate care between physician office, client, caregiver and community resources.  Provides ongoing face-to-face or telephonic visits with clients to identify barriers to accessing care, and supporting the plan of care developed by PCP and Care Manager.


• Contributes to the development of individualized care plan by using evidence-based guidelines  and clinical knowledge, for client and provider, by evaluating and conducting home visits, gathering assessment information, and  identifying problems, goals and interventions.


• Assists clients and caregivers in taking an active role in health management and promotion, through coaching, education, navigation and referrals to appropriate care and community based resources.


• Comprehensive knowledge of community and public resources serving the client population. Thorough understanding of how to access/maintain and actively assists clients to secure resources.


• Reviews adherence to physician’s recommendations, assessing  barriers to care, and documenting information for the care team.


• Develops cross-functional relationships with medical groups by attending appropriate meetings, working on-site, and structuring effective communication mechanisms.


• Exhibits strong interpersonal, critical thinking and analytical skills through positive communication with clients, caregivers, care team and community agencies.


• Demonstrates excellent organizational, decision-making and multi-tasking skills as demonstrated by problem solving and successful outcomes.


• Completes timely and accurate documentation in multiple computer systems to record assessment, observations  and corresponding documentation, including care plans, and progress notes.


• Enhances skills and knowledge by participating in educational offerings and team case conferences and training per department guidelines.


• Utilizes department desktop procedures, workflows, job aids and training material.  Identifies barriers to work processes and brings to the attention of the supervisor/manager.


• Maintains the client‘s right to privacy 


• Adheres to all quality, compliance and regulatory standards to achieve desired outcomes.


• Contributes to team effort by accomplishing related results, as needed.