Hybrid Community Health Worker- Team Lead bei PCC COMMUNITY WELLNESS CENTER

Description

Job Purpose: Assist in the daily support, training, and supervision of the CHW team. Support PCC’s  patients to improve self-management of diabetes, hypertension and/or other chronic health conditions through assessment, education and empowerment, and eliminating barriers to self-care by screening and addressing social drivers of health.

Essential Duties and Responsibilities:

• Assisting with training and directing staff to follow department workflows. Team champion for workflows designated by manager, providing training and workflow oversight to CHWs
• Takes active role with manager to co-lead meetings, check-ins, and trainings and ensure meeting minutes and follow up is completed
• Promotes teamwork and problem solves issues concerning patient care

• Provide feedback directly to employees, as well as informing manager

• Generate reports to assist with day-to-day task assignment

• Be knowledgeable and able to perform workflows in all disease management programs and TOC

• Complete the duties of a CHW including, but not limited to:
  • Complete health-related social needs (HRSN) screeners, including but not limited to Health Risk Assessments (HRA) with appropriate patients 

• • Enroll eligible patients in disease management program(s) and provide disease specific and preventive care patient education according to program requirements.

• • Monitor patients (in person or by telephone) at required frequencies and track clinical outcomes such as PHQ-9, blood pressure, HbA1c. Use worklist to identify and re-engage patients who are not participating as expected in the disease management program.

• • Support the treatment plan prescribed by PCPs, focusing on treatment adherence, side effects, other complications, and effectiveness of treatment.

• • Facilitate treatment plan changes for patients who are not improving as expected in consultation with the PCP. These may include changes in medications, treatments, or appropriate referrals for clinically indicated services outside the primary care clinic (e.g., social services such as housing assistance, vocational rehabilitation, subspeciality, mental health specialty care, substance abuse treatment, etc.).
  • Accurately document patient information, assessments, interventions and encounters
  • Cross-train in Care Coordinator work functions and execute as required.
  • Attend ongoing training and learning related to job position and duties.
  • Contribute to patient education materials and strategies to support care coordination
  • Performs other duties as required and assigned
  • Support patients due for preventative care screenings, including telephonic reminders, assisting with appointment scheduling, and reviewing reports to identify patients due for care.
  • Support patients in enrolling (in person or by telephone) in Remote Management (app-based) program for hypertension, diabetes, depression.
  • Complete remote monitoring duties within the remote monitoring platform, outreaching patients with abnormal self-reported values per workflows

Qualifications

Qualifications:

Ability to:

• Model standards of excellence in employee conduct and performance
• Work on-site at a PCC clinic at least 3 days per week, which includes community-based visits and travel between PCC sites.
• Follow through, assume responsibility, ensure accountability, and use good judgment
• Strong interpersonal skills, communication skills and confidence and persistence in seeking out providers time to review patient progress.
• Display excellent customer service during in person and telephone contact
• Ability to effectively engage patients in a therapeutic relationship, when appropriate, by telephone or face-to-face.
• Experience with or ability to learn assessment tools and interventions for hypertension, diabetes and mild to moderate depression.
• Work at a computer terminal for extended periods of time on a daily basis

Experience/Training:

• High school diploma or GED required.
• Completed CHW certificate strongly preferred; CHW certification is required to be obtained within 6 months of hire. Up to 40 hours of on-the-job time will be allotted to CHW training, if needed.
• If no CHW certificate, then MA certificate is preferred.
• Knowledge of Chicago’s West Side communities (resident of a West Side community preferred)
• English fluency required; Spanish fluency preferred

Preferred experiences include:

• Experience working with underserved, transient populations.
• Experience delivering health education
• Experience working with patients who have diabetes, hypertension and/or depression.
• Basic knowledge of psychopharmacology for common mental health disorders that is within appropriate scope of practice for type of provider filling role.
• Working knowledge of evidence-based psychosocial treatments for common mental health disorders.
• Familiarity with brief, structured intervention techniques (e.g., Motivational Interviewing, Behavioral Activation) and evidence-based counseling techniques (e.g. CBT or PST), when appropriate.

Software Knowledge: 

• Experience with MS Office applications Excel and Word required
• Knowledge of EHR (preferably Athena) preferred

Physical Demands:

• Must be able to remain in a stationary position 50% of the time.
• Must be able to move around the clinic site 50% of the time.
• Constantly operates a computer, computer printer, copy machine, and telephone.
• Occasionally positions self to maintain exertion of physical strength to move objects of 10 pounds from one level to another.
• Ability to move as needed to perform necessary assessment face to face and must be able to transport from one site to another.
• Must be able to cover other shifts as necessary.

PCC funds this position via the Wellness West Collaborative. Should the collaborative end, PCC reserves the right to discontinue the position.