Community Health Worker/Bus Driver

Job Responsibilities

• Communicates with a specified number of patients on a scheduled basis both in person (clinic or in home) and via phone.
• Facilitate needed appointments(including coordinating transportation)
• Follow up on appointments or other instructions from the health home by making home visits.
• Assist in obtaining social and/or community services for participants.
• Participate in Health Home staff meetings and trainings.
• Assist with and advance patient self-management.
• Advance patient’s health literacy related to their conditions. Including providing education pertinent to the patient’s chronic medical conditions and lifestyle choices.
• Facilitate medication management and compliance.
• Communicates with patients, families and providers to keep the entire team focused on meeting patient centered goals.
• Provides crisis intervention as needed online.
• Works with in his/her scope of work by referring patients to appropriate clinic resources as necessary.
• Keeps PCHH providers and care team informed of patient progress, barriers to care, and any changes in patient’s condition.
• Appropriate documentation for all patient interaction, including phone calls and home visits.
• Facilitates communication between patient and any needed resources or services within the community. Assists patient in navigating health care systems, Medicaid, DFS/DSS and insurance companies to obtain needed services.
• Conducts appropriate assessments of the patient’s health literacy, social determinants of health, barriers to care, and other screenings as needed.
• Assists patients with applications to include MCD, Food Stamps, and MCR assistance
• Maintains CLAIM counselor status by assisting patients with Medicare questions and revisions to their policies.
• Maintain CLAIMS training.
• Other duties as needed.
• Participates in Quality Improvement activities.
• Keeps appointments and picks up patients in a timely manner
• Schedules transportation for patients
• Coordinates efficient routes to maximize patients assisted daily
• Provides crisis intervention/hot lining as needed
• Keeps providers and care team informed of barriers to care and any changes in patient’s condition
• Appropriately documents all patient interactions, including phone calls and rides
• Conducts and documents appropriate assessments of the patient’s Social Determinants of Health, barriers to care, chronic conditions, and other screenings as needed