Field Based Community Health Worker - Columbiana, Mahoning, Trumbull County, OH

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The Field Based Community Health Worker is responsible for assessment, planning and implementing care strategies that are individualized by patient and directed toward the most appropriate, least restrictive level of care. They also Identify and initiate referrals for social service programs; including financial, psychosocial, community and state supportive services, and manage the care plan throughout the continuum of care as a single point of contact for the member. As a Field Based Community Health Worker (CHW), you will act in a liaison role with Medicaid members to ensure appropriate care is accessed as well as to provide home and social assessments and member education. The coordinator also addresses social determinant of health such as transportation, housing, and food access.

Working Schedule: Schedule is Monday through Friday an 8-hour shift between the hours of 8am to 5pm. This position is a field-based position with a home-based office. You will work from home when not in the field.

Location: Youngstown, Warren, Columbiana and surrounding communities in Ohio (Columbiana, Mahoning, Trumbull County)

Local travel up to 50% and mileage is reimbursed at current government rate.

If you are located within Ohio - Columbiana, Mahoning, Trumbull Counties market you will have the flexibility to work remotely as you take on some tough challenges.

This is a Field Based role with a Home-Based office.

Primary Responsibilities:

• Engage members either face to face or over the phone to discuss their health
• Review available member service records and relevant documentation (e.g., utilization history, functional level, stratification information, current plan of care)
• Conduct comprehensive member assessment that includes bio-psychosocial, functional, and behavioral health needs
• Utilize interviewing techniques and active listening to collect and retain member information and incorporating responses as they are presented to complete assessment
• Identify when supplemental assessments are needed and conduct supplemental assessments
• Identify member service needs related to health concerns
• Identify urgent member situations and escalate to next level when necessary
• Engage member to participate in the assessment process and collaboratively develop plan of care based on their individual needs, preferences, and objectives
• Identify member support systems available and incorporate into plan of care
• Review plan benefits and identify appropriate programs and services based on heath needs and benefits
• Integrate health care and service needs into a plan or recommendation for member care and service
• Collaborate with member to create solutions to overcome barriers to achieving healthcare goals
• Identify relevant community resources available based on member needs
• Refer members to appropriate programs and services
• Facilitate member choice of preferred provider
• Enroll members into appropriate programs and services
• Utilize motivational interviewing techniques to help member identify and understand their intrinsic goals and motivate members to engage in positive behavior change
• Coordinate member access to health-related programs, services, and/or providers
• Coordinate with providers to facilitate member care and/or services Present complex case information to interdisciplinary care team and obtain input into member plans as necessary
• Follow up with members to monitor and document completion of plan activities following standard protocols
• Provide guidance or additional assistance to facilitate execution of plans or recommendations to improve member health
• Monitor progress toward plan goals through evaluation of the effectiveness of programs and/or services provided
• Make changes to plans or recommendations based on evaluation outcomes
• Provide individualized education on preventative healthcare measures (e.g., immunization, healthcare screening)
• Educate members on health and wellness information related to disease processes
• Educate member on plan benefits available and/or how to access benefits
• Educate members on disease specific signs and symptoms of worsening condition and action to take if they occur
• Educate member on appropriate utilization of services based on need (e.g., PCP vs. ER)
• Work with internal partners to create a culture of health and wellness that promotes member health
• Plan and execute on-site health and wellness programming for members and engage members in available programs Performs other duties as assigned