JOB DESCRIPTION

POSITION TITLE: Case Manager-Certified Community Health Worker 

DEPARTMENT: Clinical Services

FLSA STATUS: Non-Exempt

REPORTS TO: Program Manager

GENERAL DESCRIPTION OF DUTIES

The purpose of this position is to support the Agency’s needs by providing support based on CRT’s Steps to Success model, the Certified Community Health Worker (CHW) is responsible for providing a wide-range of services; including, but not limited to, outreach, engagement, education, coaching, informal counseling, social support, advocacy, care coordination, and basic screening and assessments of any risks associated with social determinants of Health. As a priority, activities will promote, maintain, and improve the health outcomes of customers. Daily monitoring of customer contacts and activities within the Community is a primary responsibility.  The Certified CHW conducts assessments of customer needs and coordinates referrals to Community Renewal Team programs and initiatives, Funder services, entitlement programs, as well as, to other Community resources that conduct Case Management services.

SPECIFIC DUTIES AND RESPONSIBILITIES

ESSENTIAL JOB FUNCTIONS

The list of essential functions, as outlined herein, is intended to be representative of the tasks performed within this classification.  It is not necessarily descriptive of any one position in the class.  The omission of an essential function does not preclude management from assigning duties not listed herein if such functions are a logical assignment to the position.

• Identify/Provide outreach and engagement functions to customers in the Community.
• Identify customers in need of Case Management and/or other Outreach Engagement services; linking them with available services.

• Interview customers on and/or off site as required.
• Complete Universal Screening to determine Program eligibility.
• Assist customers in their Homes, Community, or Clinical setting.
• Establish positive and supportive relationships with the customers.
• Complete an initial interview and assessment of individual needs.
• Assess and evaluate customer needs based on the Outcome Scale Matrix (OSM).

• Facilitate referrals to Clinics and Community Support services.
• Facilitate communication/coordinate services between providers and customers.
• Coordinate/Monitor services to include comprehensive tracking of customers compliance in relation to ISP goals and objectives.
• Provide support, advocacy, and mediation services to assure customer’s overall needs and referrals are being conveyed.
• Follow-up with both customer and provider regarding ISPs.

• Document all encounters/interactions made with and/or on behalf of the customer; including all activities, ISPs, and outcomes achieved by the customers in a detailed and timely manner.
• Conduct monthly home visits with customers as needed; documenting all visits in the customer’s file.
• Conduct bi-weekly conversations with the customer either by phone or in-person; documenting all conversations in the customer’s file.

• Maintain client records in accordance with documentation requirements and standards.
• Assist clients in utilizing Community Services, including; scheduling appointments with Social Services agencies, and assisting with the completion of applications for Programs based on eligibility.
• Assist in the preparation of demographic, and other Funder reports relative to Client Services.
• Participate in Case Management team meetings.
• Provide reports to referring agencies including; but not limited to, progress reports, discharge summaries, aftercare plans, and special reports.
• Ensure all Intake information is obtained based on program guidelines, and accurately entered into STEPS and/or HMIS systems.
• Collects demographic data, conducts pre-screening, and assesses potential eligibility for CRT, Department of Housing, or other Community-based resources.
• Facilitates information and referral services, and documents outcomes resulting from such referrals.
• Facilitates customer access to Community resources, including; but not limited to food, housing, clothing, school programs, vocational opportunities or services, life skills training, and relevant Mental Health services.
• Educate customer on the proper use of the Emergency Room, and provide information for alternatives.
• Maintains a caseload of customers in need of intensive Case Management or multiple service needs.
• Complete and submit Critical Incident reports to Funder when applicable.
• Continuously expand knowledge and understanding of Community resources and services.
• Regular attendance
• Attend and complete all mandatory trainings

ADDITIONAL JOB FUNCTIONS

• Participate in, retain, and incorporate training as required.

• Provide individual counseling and facilitate groups.
• Provide effective Customer Service including; but not limited to, greeting and receiving/addressing clients with respect and dignity at all times
  • Represent Agency/Program at appropriate Community groups and coalitions.

• Provide input and make recommendations regarding Program/Departmental policies, procedures and practices
• Report to and conduct additional duties by various Funder guidelines and requirement as required
• File, copy, schedule appointments, and answer/return phone calls

MINIMUM TRAINING EXPERIENCE and health certification

Education: Bachelor’s degree from an accredited college or university required; Education may be substituted with experience on a year-by-year basis.

Minimum Years of Experience: Two (2) years of experience providing community-based, direct client services to population experiencing Substance Abuse, Homelessness, Mental Illness and/or low income required. Experience in the medical field such as, EMT or Certified Nursing Assistant (CAN) and knowledge of medical terminology preferred. 

Certifications: Must have a CT Community Health Worker certificate or be able to obtain the certificate within six months of taking the position required.

Knowledge of: Working with the chronically homeless population preferred; Housing First and Harm Reduction Intervention strategies, Motivational Interviewing techniques required. 

Demonstrate skills in: Ability to work with individuals from diverse racial/ethnic and economic backgrounds; Solid understanding of the dynamics of Homelessness, and being at risk of Homelessness; Ability to offer strength-based Case Management; Ability to communicate effectively with Customers, Funders, and Vendors; Ability to function independently in a Community setting; Ability to interact with the Homeless, and develop trusting relationships; Ability to set therapeutic boundaries with clients; Ability to establish good working relationships with staff and Community agencies; Ability to work with a multi-disciplinary team; Ability to decide what presenting conditions are of priority; Ability to plan and organize assigned duties; Computer proficiency in Microsoft Outlook, Excel, Word, PowerPoint; Financial Literacy Skills are all required.

Driving Requirements: Maintain a valid State of Connecticut Driver’s License in good standing, and have the ability to take your personal vehicle into the Community required.  

ADA COMPLIANCE

Physical Ability: Tasks involve sedentary to light work, involving some reaching, handling, fingering and/or feeling of objects and materials.

Sensory Requirements: Some tasks require visual perception. 

Environmental Factors: Tasks are regularly performed without exposure to adverse environmental conditions, such as dirt, dust, pollen, odors, wetness, humidity, rain, fumes, temperature and noise extremes, machinery, vibrations, electric currents, traffic hazards, animals/wildlife, toxic/poisonous agents, violence, disease, or pathogenic substances.