Community Health Worker (Remote)

Department:                 Care Management

Reports To:                  Manager of Families and Children Care Management

Status:                         Full Time, Non-Exempt

Hours:                          Monday – Friday

Supervision:                This position does not supervise any other staff

Summary:        This position focuses on improving the health status and social drivers of health of PrimeWest Health members, both individually and as a community. The Community Health Worker (CHW) is an essential part of the PrimeWest Health Care Management team and is responsible for primarily working in the community with members who benefit the most from their services. CHWs are trusted, knowledgeable frontline health personnel who typically come from the communities they serve. CHWs bridge cultural and linguistic barriers, assist with access to care, address social drivers of health, and improve health outcomes. As critical links between their communities and the Care Management team, CHWs work to reduce health inequities, boost cultural competence, and empower individuals and communities to achieve better health through advocacy, education, and support. CHWs play an integral part in reducing emergency room use and unplanned hospitalizations; increasing access to holistic, integrated health and dental care; and connecting members to covered services. The CHW works closely with medical and behavioral health providers, primary care teams, care coordinators, county partners, and other agencies to improve member care and outcomes. CHWs travel by automobile throughout their community in order to carry out some of their job responsibilities.  

Reporting Accountability This position is responsible for meeting the following regulatory, contractual, or other requirements on behalf of PrimeWest Health:

1. Knowledge of Minnesota Department of Human Services (DHS), Centers for Medicare & Medicaid Services (CMS), and National Committee for Quality Assurance (NCQA) requirements
2. Reporting responsibilities, including the following:

Annual Population Health Management reports, including satisfaction surveys

Role and Key Responsibilities
Assist PrimeWest Health Care Management staff in the following activities as needed:

1. Clinical/Professional Functions

Assist in administering the Care Management program for assigned members. This includes the following:

1. Explain the purposes and services of the Care Management program to the member, as well as the benefits that participation in this program includes
2. Work with the member’s interdisciplinary team, providing input into individualized care plans
3. Help members overcome social drivers and barriers to care.
4. Assist each member in understanding their individualized care plans and instructions.
5. Update the interdisciplinary team on observations made while working with members in their homes and communities, alerting team members to areas that require intervention

• Coach and motivate members to be active and engaged participants in their health, overcoming barriers to obtaining needed medical care and social services
• Document activities, service plans, and results in an effective manner in an appropriate health records system while strictly adhering to the policies and procedures in place
• Establish positive, supportive relationships with participants
• Help members access services, including scheduling appointments, obtaining a medical home, and post-discharge follow-up; accompany members to provider visits and appointments with community resource agencies; and assist with completion of applications for programs for which they may be eligible
• Facilitate communication and coordinate services between providers
• Build and maintain positive working relationships with providers, case managers, agencies, etc. from diverse backgrounds in order to reduce cultural and socio-economic barriers between members and institutions Continuously expand knowledge and understanding of community resources, services, and programs
• Complete follow-up calls and telehealth and face-to-face visits to identified members
• Contact the Manager of Families and Children Care Management and providers with concerns about identified members Provide social support and informal counseling Collect data to help identify community health needs, advocate for these needs for underserved individuals and communities, and educate health care providers and stakeholders about community health needs
• Monitor reports detailing member health, emerging risk, safety, outcomes across settings, and chronic conditions
• Create connections and help manage care transitions between vulnerable populations and health care providers
• Reduce social isolation among members; provide social support, informal counseling, health screenings, and referrals
• Promote cultural competence among health care providers serving vulnerable populations
• Provide culturally appropriate health education on topics related to chronic disease prevention, physical activity, and nutrition
• Collect data and relay information to stakeholders to inform programs and policies
• Build individual and community capacity to achieve wellness by addressing health issues and social drivers of health
• Demonstrate understanding, appreciation, and awareness of cultural, social, and economic diversity within the community being served Healthcare Effectiveness Data and Information Set (HEDIS^®)[1] Score Improvement and Member Engagement Focus on improving applicable HEDIS scores Collaborate with other identified staff and/or departments (e.g., Quality & Utilization Management and Member & Provider Services) to identify additional quality improvement projects aimed at improving HEDIS scores and/or member engagement activities, including the member activation program Administrative Functions Track members using spreadsheets to ensure follow-up is conducted as needed Coordinate assigned member mailings Enter assessments and notes into electronic medical records Review forms and reports for accuracy Assist with county case manager trainings Other Duties Collaborate with providers, county case managers, and PrimeWest Health care coordinators as indicated Assist with updating applicable PrimeWest Health policies and procedures
• General PrimeWest Health Responsibilities

1. Abide by the PrimeWest Health Code of Conduct Comply with all PrimeWest Health policies and procedures Comply with the Health Insurance Portability and Accountability Act (HIPAA) and all other privacy laws Be familiar with building safety procedures and alert maintenance if something requires attention Keep public areas of the department and office neat and clean Conduct other responsibilities and activities as needed and assigned

• Professional Competencies

1. Effective active listening skills Strong non-judgmental communication skills Ability to model effective problem-solving skills Ability to work effectively with minimal supervision and structure Practice knowledge of clinical standards and outcomes Ability to assess and set goals, develop interventions, and conduct follow-up Ability to conduct critical analyses Ability to promote member and family autonomy Ability to give presentations, conduct telephone assessments, and participate in community meetings Ability to maintain a calm demeanor when challenged by others or when working in stressful situations Verifiable good driving record and reliable transportation

• Educational Requirements and Required Qualifications

1. Licensed Practical Nurse (LPN) diploma or certified/seeking certification as a CHW Bachelor’s degree in a health-related area preferred Knowledge of, and proficiency in, Word, Excel, and Outlook required; experience in relational databases and business information systems preferred Flexibility and ability to handle multiple tasks. Demonstrated organizational skills and attention to detail. Ability to work effectively with a variety of people both within and outside of the organization. Excellent verbal and written communication skills. Ability to work well under pressure in a fast-paced environment. Ability to sit at a desk or computer station most of the time. Ability to occasionally lift and/or carry such articles as file folders and small boxes up to 30 pounds.

• Appropriate Licensure and Certification Requirements

1. Must possess current and unrestricted LPN license or Must possess current and unrestricted CNA license or Must possess current and unrestricted CHW certificate or be actively pursuing this certificate. Must attend continuing education sessions annually to support license requirement Must possess current and unrestricted drivers license

• Collaborative Efforts with Other Departments

1. Administrative Services Corporate Compliance & Auditing Information Systems & Technology Member & Provider Services Quality & Utilization Management Business IT & Claims Administration

• Supervision – N/A 

  This position description is not to be construed as an exhaustive statement of essential functions or responsibilities.

  PrimeWest Health is an Equal Opportunity Employer Committed to Diversity, Equity, and Inclusion