Patient Engagement CHW in Bangor, Michigan at InterCare Community Health Network

NewSalary: $20
InterCare Community Health Network
Bangor, Michigan, 49013, United States
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Job Description

InterCare is a Federally Qualified Health Center which MAY qualify employees for National Student Loan Forgiveness program.

Become part of a Migrant and Community Health Center, where you will:

  • Have a passionate purpose.
  • Do worthwhile work.
  • Make a difference in people’s lives.

InterCare is searching for a Patient Engagement Community Health Worker to join our team in Bangor at our Administration building! At InterCare, you’ll find a rewarding and challenging work environment and a competitive compensation and benefits package which includes: vacation/personal paid time off, sick time, 10 paid holidays, tuition reimbursement program, medical, prescription, dental, vision, life insurance, and short term and long term disability insurance.

InterCare NO LONGER requires employees to have the COVID vaccine, however, you may receive a vaccine at no cost at any of our clinic locations.

Work Schedule:

Primary hours are Monday - Friday from 8:00am - 4:30pm, with some evening hours as necessary.

Primary Accountability

Responsible for improving patient engagement by assisting patients in increasing access to health services through outreach, encouraging engagement, education, and peer support. The patient engagement CHW is part of an inter-disciplinary clinical care team supporting the health centers in patient engagement activities through outreach and follow up.

Description of Primary Duties & Responsibilities

  1. Performs patient outreach and tracking responsibilities.
    1. Performs an initial assessment based upon the reason provided for contact such as; no care with PCP during current year, Health Risk Assessment completion, inappropriate ED use, recent hospitalization, gap in routine care, and connection to community resources to address SDOH issues.
      1. Effectively uses a variety of communication methods to engage with patients, such as coordinated text messaging, phone calls, mail and in-person visits at home, other care settings or community events.
    2. Reviews MCHN provided monthly outreach list for each covered Health Plan and develops a plan for prioritized outreach following MCHN best practices workflow.
    3. Documents all outreach attempts in MCHN provided documentation tool and provides results monthly to allow for aggregate reporting to Health Plans.
    4. Provides direct education or engagement with contacted patients, or connects to other resources for education as appropriate, based upon initial assessment.
      1. Appropriately provides patient education on appropriate use of health services, assists with federal, state and local programs that provide or financially support the provision of medical, social, educational, housing, or other related services, and addresses identified factors impacting health outcomes (e.g., social, housing, educational).
    5. Conducts Health Michigan Plan Health Risk Assessment, contacts identified patients in need of completing the assessment and assists contacted members in completion of the assessment and addresses triggered interventions.
    6. Assists in closing the gap in care, by utilizing individual and MCHN provided reports to prioritize patient outreach attempts (e.g. missing preventive service, poor chronic disease outcome etc.) and facilitating the scheduling of required visit / testing and eliminate barriers to care as appropriate.
    7. Assists health center staff in maintaining assigned patient panels with covered Health Plans including helping patients change primary care provider and supporting the health centers in removing patients that are not served by the health center from its panels.
    8. Actively collaborate with other members of the primary care team including Care Managers, Support Staff and PCPs.
  2. Promotes Patient and Community Engagement through a variety of methods.
    1. Coaches and motivates patients to engage in primary care to effectively manage their chronic disease or engage in preventive care as appropriate.
    2. Assists assigned members in the navigation of the health care system and to help address common barriers to care including; securing a PCP and scheduling primary care appointments, and updating health plan records to reflect actual PCP.
    3. Coordinates a graduated intensity outreach program for newly assigned patients to engage patient in their care. Effectively provides information about the health center, its services, and helps patients prepare for their first visit.
    4. Documents all outreach attempts following MCHN workflow to allow for patient reassignment by Health Plan as appropriate.
    5. Contacts patients weekly who are at high risk by stratification methodology and engages the individual in care management and coordination services/programming provided by the health center.
  1. Assists patients with Community Resources/Social Determinants of Health (SDOH) and follows up on inappropriate and preventable Emergency Department (ED) utilization.
    1. Address Social Determinants of Health (SDOH) issues identified during patient contacts and eliminate barriers to care as appropriate.
    2. Conducts SDOH screening and assessment using tools identified by MCHN to uncover individuals needs and connects members with available community resources addressing, SDOH such as, food, housing, transportation, economic stability, social and community connectedness, neighborhood, health and health care.
    3. Contacts assigned Health Plan members identified as either high or inappropriate utilizers of the ED and encourages engagement with PCP.
    4. Provides education and resources to identified high or inappropriate utilizers of the ED. Encourages member to contact PCP to provide the opportunity to address need through health center services.
    5. Addresses identified barriers to care that led to the utilization of ED rather than Primary Care services.

Description of Primary Attributes

General Development

  1. BCLS Certification is required.
  2. Ability and willingness to provide emotional support, encouragement and motivation to patients.
  3. Ability to work effectively with a wide variety of people and maintain positive working relationships with site staff, clients, providers, clinical support staff, agency representatives, and management.
  4. Possesses skills in motivation, self-direction, and punctuality.
  5. Ability to work well as part of a team and keep team members updated on current project developments
  6. Ability to continuously expand knowledge and understanding of community resources, services and programs provided; human relations and procedures used in dealing with the public as part of a service or program.

Professional and Technical Knowledge

  1. Possesses a high school diploma or equivalent.
  2. Successful completion of 126 hours of the Community Health Worker Michigan-specific training.
  3. Maintains BLS requirement. BLS is a mandatory by InterCare and our FTCA agreement with the Federal Government. It must be completed within 90 days of hire.

Technical Skills

  1. Basic to intermediate level skills in Microsoft Office Suite.
  2. Ability to present educational information to patients one-on-one or in group settings.
  3. Ability to create letters, forms, documents, presentations.
  4. Knowledge of medical terminology preferred.

Communication Skills

  1. Possesses a professional level of written and verbal communication skills.
  2. Ability to communicate complex concept in a clear effective manner.
  3. Possesses excellent cross cultural communication skills and the ability to communicate to staff members at all levels.
  4. Fluent in Spanish and English, reading, writing, and speaking skills.

Physical Demands

Job duties are performed during irregular evening hours outside of the typical office environment. The environmental factors and/or physical requirements of this position include the following:

  1. In-home and warm weather outdoor work with occasional in-office work.
  2. Extensive travel using reliable personal vehicle.
  3. Ability to stand, walk, stoop, kneel, crouch, frequently sit, and lift up to 25 lbs.
  4. Requires ordinary ambulatory skills sufficient to visit other locations.
  5. Requires good hand-eye coordination, reach with arms & hands, and finger dexterity, including ability to grasp, and manipulate (using keyboard, office equipment).
  6. Visual acuity to use keyboard, operate office equipment, and read printed material and regularly required to talk and hear.

08:00am-04:30pm Monday through Friday

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Job Location

Bangor, Michigan, 49013, United States

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