POSITION SUMMARY

Our Community Health Workers (CHWs) are strong patient advocates. Building trust with our patients, their families and our community and bringing an encouraging spirit to the position are two keys to being a successful Community Health Worker.  CHWs support our mission by creating community outreach programs and activities that are designed to promote, maintain and improve the health of the patients and families we serve. Given the CHWs’ necessary interactions with patients, families, staff, providers, residents/fellows, social service agencies and other Community Based Organizations, private, state and federal insurance programs, and others, excellent communication skills are an absolutely necessary characteristic for effective CHWs. 

As a CHW, the Director is responsible for leading the Community Health Workers (CHWs) and responsible for the oversight and coordination of patient centered services in the areas of medical case and care management, lifestyle and nutrition services as well as geriatric and Alzheimers and Dementia services. This position leads various patient-, community- and family-centered activities on behalf of The Wright Center entities (collectively, “TWC”), and liaises regularly with the volunteer Directors on TWCPCE as well as TWCCH. An important addition to the Care and Case Management (C/CM) Department, this position works closely with the C/CM team as well as the Director of Community Outreach and Engagement (CO&E) and the Board of Directors of TWCPCE in developing, organizing and implementing patient- and family-centered care improvement and wellness initiatives, capturing all clinically billable activities and properly documenting those activities to promote stewardship of resources.  This position also supports the work of TWC in its commitment to continuously develop and enhance TWCGME’s population health curriculum to ensure that America’s physician workforce is community-competent as well as compassionate. 

To force multiply the impact of this role, the Director Patient Centered Services & Outreach and Co-Director PCE also serves in a volunteer capacity as one of three Co-Directors of TWCPCE (in partnership with the Community Outreach & Engagement Director and Director of Patient Engagement & Behavioral Health Outreach). Affiliated with TWCCH, TWCPCE is a tax-exempt, Pennsylvania non-profit organization established to support the education of, advocacy for and empowerment of patients and families. This position will engage and organize patients and families, staff and residents, and the community to increase levels of engagement across the board to improve health outcomes.

ESSENTIAL JOB DUTIES and FUNCTIONS

While living and demonstrating our Core Values, this position will:

Community Health Worker

• Takes direction from and works closely with the AVP, Integrated Primary Health and the C/CM team in addressing patients’ needs as they relate to Geriatrics/A & D, Lifestyle and Nutrition, and primary care service
• Helps patients identify social and economic issues that affect their overall health and develops responsive health/social management plans and goals
• Educates patients on the proper use of the Emergency Department and provides information for alternatives by coaching patients in the effective management of their chronic health conditions and self-care
• Assists patient in understanding care plans and instructions
• Motivates patients to be active and engaged participants in their health and overall wellbeing
• Provides support and advocacy during initial medical visits or when necessary to assure patients’ medical needs are met and necessary referrals are activated
• Follows up with both patients and providers regarding health/social services plans  
• Travels to regional hospitals as needed or as requested to support patient needs
• Continuously works to expand knowledge and understanding of community resources and services available to our patients and their families
• Facilitates patient access to community resources, including locating housing, food, clothing, prenatal classes, parenting, and relevant mental health services
• Assists patients in utilizing community services, including scheduling appointments with social services agencies and assisting with completion of applications for programs for which they may be eligible
• Facilitates communication and coordination of services between providers and the patients
• Coordinates and monitors services, including comprehensive tracking of patients’ compliance in relation to care plan objectives
• Works to reduce cultural and socio-economic barriers between patients and institutions
• Responsible for oversight of remote patient monitoring devices

Patient Engagement

• Takes direction from and works closely with from the AVP, Development and Patient & Community Engagement, the Director BH Outreach and the TWCPCE Board of Directors on developing, planning, implementing and reporting on projects and initiatives arising from TWCPCE’s strategic plan
• Takes the initiative to identify and propose patient engagement events/programs based on community health needs assessments and TWCCH SDOH screens, and once approve, develops and implements the Project Plan with Budget for approval
• Works constructively with Practice Managers in all clinical locations to address non-medical patient complaints and concerns
• Under the direction of the AVP, Development and Patient & Community Engagement, the PO&E Director partners with the Marketing & Communications Department and Director Patient Engagement and BH Outreach on all community outreach events/projects 
• Ensures timely transfers of information and responses to patient and staff inquiries for support
• Assists patients in understanding their rights and responsibilities
• Demonstrates superb listening skills, compassion and diplomacy when listening and interacting with patients, families, and clinical staff
• Continuously evaluates work process and design, leading the development or improvement of the existing TWCPCE infrastructure
• Organizes and administers patient support groups corresponding to identified needs within the organization.
• Develops, maintains, and shares a listing of patient support groups within the organization and the wider community.
• Assist provider in referring patients to patients support groups.
• Serves as a liaison in proving content area expertise from the organization to support groups.
• Embraces the identity as champion of quality assurance and quality improvement in this innovative hybrid clinical/administrative role that also directly interacts with nonprofit governance 
• Coaches and mentors staff and volunteers who have patient contact in order to achieve higher levels of patient satisfaction
• Attends all TWCPCE and TWCCH Boards of Directors meetings and all relevant Committee meetings as directed
• Attends meetings, conferences and trainings relevant to patient engagement and social and economic determinants of health
• Collects, assesses, tracks and reports data related to patient engagement initiatives and patient/community needs
• Attend meetings such as practice huddles, manager meetings, and explore opportunities for meaningful community partnerships to improve patient health outcomes
• Perform other duties as assigned

• High school diploma or GED; at least three (3) years’ experience directly related to the duties and responsibilities specified
• Must obtain Community Health Worker Certification within one (1) year of employment
• Current BLS certification
• Bilingual highly preferred
• Strong computer skills MS Office Suite and Gmail Experience with electronic health records a plus
• At least five (5) years of change management and/or customer service program leadership experience required, preferably in a healthcare setting; prior patient engagement experience preferred but not required
• Must demonstrate the ability to use discretion and independent judgment to make difficult decisions
• Must demonstrate a comprehensive understanding of general patient care functions and processes (i.e., nursing, billing, call center, etc.)