Community Health Worker- Chronic Care

Job Summary

This Rural Health Transformation Program is supported by the Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $206,927,896.80 with 100 percent funded by CMS/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CMS/HHS, or the U.S. Government.

The Community Health Worker (CHW) supports patients with chronic health conditions and/or social needs that may affect their health or ability to access care. Chronic conditions may include, but are not limited to, heart failure, hypertension, COPD, diabetes, obesity, and kidney disease. Social needs may include isolation or lack of support, financial or utility concerns, housing or transportation challenges, food insecurity, and health literacy needs. Services will vary based on the individual needs of the patient and may be provided in the clinic, hospital or other healthcare facility, community, or patient’s home.

The CHW develops trusting relationships with patients and families and provides education, support, and resources to promote risk-factor reduction, preventive care, self-management, and improved health outcomes. The CHW assists with care transitions, serves as a liaison between patients, caregivers, healthcare teams, and community resources, and advocates for patients in both outpatient and inpatient settings.

Under the supervision and direction of a provider or other qualified healthcare professional, the CHW performs a wide range of activities designed to assist patients in gaining, regaining, or maintaining healthy life skills. The CHW works collaboratively with the nursing team, Program Director, providers, and other members of the healthcare team to support continuity of care and patient engagement.

The CHW must successfully complete a designated certification course within the first 90-days of employment plus in-house, tailored training. Training will include Motivational Interviewing. Training proficiency will be demonstrated through a combination of approximately 50% e-learning and 50% supervised real-life application

The CHW will perform administrative and care coordination duties, including scheduling appointments and services, documenting activities in the medical record, data abstraction, and maintaining program-related documentation. The CHW will make patient/client telephone calls, participate in telehealth encounters, conduct in-person visits, and oversee remote patient monitoring activities under the direction of the qualified healthcare professional team.

The CHW will assist the nursing team and program leadership along with the Maternal Health and Residency Telemedicine programs as needed. Performs other duties as assigned.

Minimum Job Requirements

• High school diploma or its equivalent.
• Community Health Worker certification or must obtain within 90 days of employment.
• Valid Indiana driver's license and insurance.
• Dependable transportation with ability to travel between healthcare facilities, community locations, and patient homes as required by the position.

Preferred Job Requirements

• Previous experience as a Community Health Worker, Patient Navigator, Care Coordinator, Medical Assistant, Health Coach, or in a comparable healthcare/community-support role.
• Community Health Worker certification or completion of a recognized CHW training program.
• Experience in a rural healthcare, hospital, clinic, community health, public health, or social service environment.

Skills / Knowledge / Abilities

• Knowledge of healthcare policies and governmental regulations pertinent to chronic care management and the community health worker.
• Sufficient knowledge to observe and report changes in client condition.
• Culturally competent.
• Excellent communication skills to communicate effectively and tactfully with patients, as a representative of Marion Health.
• Interpersonal skills necessary to carry out duties independently and in a professional manner.
• Highly developed computer skills to include proficiency with Microsoft Office (Word, Exell and email) and the ability to learn and proficiently perform computer applications related to operations and job function.
• Highly developed computer skills to include proficiency with Microsoft Office (Word, Excel and email) and the ability to learn and proficiently perform computer applications related to operations and job function.
• Ability to be discreet and protect the integrity of any confidential matter or information encountered during the performance of job duties.

Working Conditions

• Typical clinical environment with prolonged sitting and occasional standing and walking.
• Work may be subject to interruptions.
• Works with highly confidential information which may be proprietary or protected health information.
• Driving to patient homes and home encounters with patients.
• May attend special functions and meetings at various locations within the community.

Physical and Mental Activities, Tools and Equipment

• Uses computer and standard office equipment.
• Uses own vehicle to visit patients.
• Lifting, pushing, pulling, walking, sitting, reaching, bending, kneeling or stooping to perform duties in a safe manner.

Equal Opportunity Employer Marion Health is a smoke-free environment.