Job Description

About Grace at Home

Grace at Home is an innovative health and care company on a mission to eliminate barriers and improve care in high-need, urban, and rural communities. Grace at Home’s purpose is to improve the health and well-being of those who need care the most—every day, in their homes and communities.

Overview

Reporting to the Community Care Manager, the Community Health Worker is a member of the Grace at Home interdisciplinary care team, providing in-home support to Grace at Home family members and their families as they navigate the often-complex healthcare systems. This role serves as a vital link between members, their communities, and care providers. Through addressing individual members’ unique barriers to care and social determinants of health, the Community Health Worker ensures improved health outcomes and overall quality of care in coordination. They are a member advocate, ensuring that their voices are heard and their needs are met within the healthcare system. This position is a community-based position that will require you to be in the community and meeting with members face to face in their homes, at doctor appointments, libraries, or other locations within the community agreed upon by the participant and the CHW.

Duties & Responsibilities

• Establish rapport with patients and their families to facilitate open communication and understanding of their health needs during transitions, providing patients with essential information about their health conditions and self-management strategies, as directed by the clinical team.
• Conduct in-home monthly or bimonthly visits with members based on risk stratification.
• Conduct telehealth video visits with appropriate clinical or social resources to address the member’s real-time clinical, behavioral, or social needs. Ability to utilize appropriate monitoring equipment for telehealth video visits.
• Collaborate with healthcare providers, social workers, and community organizations to ensure that patients receive comprehensive care. This includes scheduling follow-up appointments, arranging transportation, and coordinating home health services.
• Assist members in navigating insurance and healthcare policies, accessing community resources such as financial assistance programs, housing support, and healthcare services to help them manage their health effectively.
• Be sensitive to the diverse cultural backgrounds of patients, ensuring that care is respectful and tailored to individual needs.
• Utilize evidence-based assessments and approaches to help members identify and prioritize their health, address social challenges, and utilize community-based resources.
• Establish and maintain working relationships with primary care providers, interdisciplinary teams, and community-based programs to ensure coordinated care for members.
• Engage in care coordination efforts to assist members in identifying barriers to health and well-being and collaborate to address those challenges effectively.
• Accurately document all visits and member interactions in the electronic medical record (EMR) and team tracking systems.
• Maintain detailed records to ensure continuity of care and assist in monitoring the progress of members.
• Perform other job-related duties as assigned.

Qualifications

• Education: Associate degree or a combination of education and experience required; B.S. or B.A. preferred.
• Experience:
  • 2+ years in the healthcare arena or exposure to healthcare systems required.
  • Experience as a Community Health Worker or equivalent supporting vulnerable populations required.
• License: Unrestricted driver’s license in home state required.
• Skills & Abilities:
  • Ability to work collaboratively with healthcare teams and community organizations to address the complex needs of participants.
  • Experience working with electronic medical records (EMR) and care management systems.
  • Strong knowledge of HIPAA regulations and ability to handle sensitive and confidential information with discretion.
• Certifications: CPR certification is required. CHW certification is a plus.
• Communication: Excellent verbal, written communication, and presentation skills; ability to clearly articulate and present concepts and models in an accessible manner to the team and members, with the ability to build trust and rapport, in person and over the phone, with individuals from diverse backgrounds.
• Relationships: Ability to build and effectively manage relationships internally and externally.
• Culture: Good judgment, impeccable ethics, and a strong team player; desire to succeed and grow in a fast-paced, demanding, and entrepreneurial company.

Benefits

Grace at Home provides all employees working an average of 30+ hours/week with a comprehensive benefits package, including the option to enroll in healthcare benefits. The cost of healthcare is shared between the company and the employee.

The working environment and physical requirements of the job include:

This position requires in-home, assisted living, and independent-living community-based work. The job requires frequent travel for patient visits in all types of weather conditions. Work may be performed in settings with conditioned air, artificial light, and an open workspace.

In this position, you will need the ability to travel frequently by car and/or public transportation, and the ability to communicate with customers, vendors, management, and other co-workers in person and via devices, sometimes with people who are agitated. Regular use of the telephone and email for communication is essential. Sitting or standing for extended periods is common. Must be able to receive ordinary information and to prepare or inspect documents. Lifting of up to 50 lbs. occasionally may be required. Good manual dexterity for the use of common office equipment such as computer terminals, calculators, copiers, and fax machines. Good reasoning ability is important. Able to understand and utilize management reports, memos, and other documents to conduct business.

Equal Opportunity & Reasonable Accommodation Statement

Grace at Home is an Equal Opportunity Employer committed to creating an inclusive environment for all employees. We provide equal employment opportunities to all individuals regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected characteristic under applicable law.

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