Summary: Conducts advanced outreach to community. May coordinate charitable programs. Develops relationship with community and community leaders Responsibilities: • The Community Health Worker (CHW) provides culturally appropriate support and information for the patient and their families in a ries of structured visits and follow-up phone calls in a variety of settings, including the patient’s home • Knowledge of resources in the community and refers patients to them • Assists patients in their understanding of how to use healthcare and social services and manage their Patient Health Record (PHR) • Has a holistic and interdisciplinary approach to care management and health promotion • Builds relationships with the patient, their families, healthcare providers and the community • Assist patients in finding and understanding how to use a Medical Home (patient’s primary choice of physician or clinic), pharmacy assistance programs, dental services, diagnostic services, transportation, behavioral health services and other services as needed • Refer patients to healthcare and social services and follows-up on all referrals • Follow care pathways (evidence-based steps) designed and selected to deal with patients’ specific health and social concerns and problems • Document activities through appropriate record keeping that follows the organization’s policies and procedures • Maintains patient registry • Consult with administrative supervisor and clinical supervisor to coordinate activities and schedule and to address identified health care needs of the patient • Educate patients and their families in healthy lifestyles and promote health behavior change • Encourage patient to set goals, identify barriers and challenges and monitor their own conditions Requirements: • Bachelor's Degree preferred Work Schedule: 12:30PM - 9PM Work Type: Full Time