Reporting to the Manager of Community Health Social Services (MCHSS), the Community Health Worker - Transitions of Care (CHW-TOC) works in collaboration with patients, families (as defined by the patient), and staff across program specific disciplines and departments and to provide care coordination and resource information for patients in the hospital and health center setting.

Essential Duties:

• Facilitates and supports hospital transitions to care to CommUnityCare Health Centers.
• Creates new patient charts to assist patients in establishing care
• Collaborates with all team members of the hospital care team
• Collaborates with external partners, including hospital staff and Central Health, on patient transitions for complex care
• Attends daily patient care (unit) huddles and periodic informational (clinic) huddles, meetings, patient conferences, or planning sessions. These may be related to quality assurance, patient care and other related topics within the hospital and clinic.
• Participates in the identification and intervention of Social Drivers of Health needs for internal and external referrals.
• Acts as a patient and family advocate to ensure that services are delivered to meet the needs of patients and families, as well as appropriate use of resources.
• Coaches and supports patients through the various financial screening applications processes. Completes all direct and indirect care documentation in timely manner and ensure patient records are current and complete.
• Supports transitions of care to primary care providers across our various CommUnityCare health centers.
• Maintains ongoing communication with community partners and attends various community events to promote education and awareness of safety net programs as assigned by Supervisor.
• Collaborates with all members of the care team in providing patient-centered care.
• Provides cultural mediation between community members and CommUnityCare.
• Empowers patients and/or their families to be an engaged and active participant in their care.
• Helps patients and families set personal goals and attend appointments.
• Coaches patients in effective management of their health conditions and self-care.
• Serves as liaison between the patient and healthcare systems, assisting as needed.
• Interfaces with providers and clinic team to ensure that the patient follows with the provider’s treatment plan.
• Interacts with patients via phone calls, medical or social services appointments, and other locations per program guidelines, to bridge the gap between systems.
• Advocates for individual and community health needs and perform outreach activities within the community as assigned by Supervisor.
• Maintains privacy and confidentiality of patient’s medical records and visits.
• Ensures all tasks provided and associated with patient care, patient administrative processes and related duties comply with all regulatory and accreditation standards including The Joint Commission and CommUnityCare Standard Operating Procedures and CommUnityCare Policies and Procedures.
• Develops and maintains favorable internal relationships, partnerships with co-workers, including clinical managers, clinical support staff, providers and business office staff.
• Interacts respectfully and collaboratively with patients and their families, striving to develop favorable relationships with families.
• Participates in quality strategies to evaluate compliance with evidence-based guidelines, standards and to identify opportunities to improve patient outcomes.
• Attends seminars and maintain all licensure and/or certification requirements for continuing education and best practices.
• Seeks opportunities and implement goals for own professional development.
• Performs other duties as assigned.

Knowledge/Skills/Abilities:

• Strong interpersonal skills.
• High level of skill at building relationships and providing excellent customer service.
• Excellent verbal and written communication skills.
• High level of problem solving skill to better serve patients and staff.
• Strong attention to detail and accuracy.
• Excellent skills in public speaking.
• Ability to communicate in various settings, including but not limited to group presentations and small-scale meetings.
• Bilingual (Spanish/English) preferred.
• Ability to work with diverse groups of people.
• Demonstrated familiarity with tools, technology, and systems typically found within most health care environments, (i.e. EHR, personal computer skills, including Microsoft Office)

MINIMUM EDUCATION: Graduated from a high school or equivalent

MINIMUM EXPERIENCE: 2 years of experience working within a community health setting in a health care role or a community based human service agency as a Community Health Worker (CHW), health educator, community outreach worker, or community organizer.

REQUIRED CERTIFICATIONS/LICENSURE:

• Certified Community Health Worker (CHW) or completion of an approved 160‐hour competency based Community Health Worker training program certified by DSHS within the first six (6) months of hire.
• Valid Texas Driver’s License with no outstanding driving violations; access to personal vehicle with proof of insurance. Upon Hire