Community Health Worker, Integra

The Community Health Worker is a member of the community health team; an interdisciplinary team comprised of Community Health Workers, In-Home team nurse care managers, schedlers, resource specialists, health navigators, and nurse practitioners. Works closely with the core team members to support patients who are dealing with complex medical, behavioral health and/or substance issues as well as social determinants of health, and require a more intensive home and community-based intervention. Duties and Responsibilities Assist the Integra In-Home patients in securing community resources identified through the SDOH screening and in-home assessment. Act as a liaison between the patient and the community resource. Be responsible for the SDOH screening and assessment of the patients' needs to remain in the community. Assist with the management of the newly implemented chronic condition disease management programs for BCBS members. Assess patient needs, offer community resources and referrals, provide navigation, support, care coordination, and ongoing case management to meet those needs. Visit patients in their homes and communities, providing culturally sensitive approaches to health information to improve health literacy. Facilitate the patient’s decision-making and self-management to help patients engage in their overall health and achieve their health goals. Track patient-related activities, monitor and document progress. Work collaboratively with the primary care team to promote patient-centered care and actively participate in multidisciplinary patient-centered team meetings. Maintain frequent contact with community agencies on behalf of the patients served, networking and collaborating on resource identification to improve the overall health of the population. Requirements High School diploma required with a combination of training and skills to effectively carry out responsibilities and assignments (such as previous experience working with patients in a community-based setting). Must have Certification in Community Health Work or be working toward certification, must obtain certification within 12 months. Associates or Bachelor’s degree in Social Work, Community/Public Health or related health sciences field a plus. Experience working with primary care providers or in other healthcare settings. Experience working with patients regarding managing their health, navigating systems, providing care coordination and health coaching is preferred. The ability to travel to various locations in the state and reliable transportation is required. Must possess a valid, current state issued driver’s license, have reliable transportation and proof of current auto insurance required. Ability to speak a second language, Spanish preferred.

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