Job Description


Under the direction of the Director of Behavioral Health, the Behavioral Health Community Health Worker (BH-CHW) is a trusted member of the community who facilities the care of high risk patients to promote adherence to key components of their health care. The community health worker engages patients, creates a trusting relationship, and provides care coordination to manage members with severe mental illness who have high rates of behavioral health utilization and/or severe psychosocial vulnerability. The CHW will make patient visits in the home, community, Emergency Department, hospital or other setting, sets health goals and closely communicates with the provider and care team. Provides support and assists members in understanding the implications and complexities of their current medical situation and/or overall personal care.


• Provides community health worker services to high risk patients that have Behavioral Health and Social Determinates of Care Needs
• Initiates telephonic or face to face contact with high risk patients
• Schedules and completes initial comprehensive assessment, develops a patient centric plan of care and follow up schedule within specified timeframes
• Works with the patient, family/caregiver provider and other care team members such as physician, social worker or nurse to set goals for patient's care, identify any barriers to care, and motivate patients to achieve those goals.
• Acts as a liaison and member advocate.
• Provides care coordination and care management to members with severe mental illness who have high rates of behavioral health utilization. Works towards achievement of optimal clinical and resource outcomes.
• Teaches key educational messages in person and over the phone and utilizes teach back methods to measure and ensure patients understanding
• Clearly documents all activities in the patient record
• Records and monitors the participants' progress toward goals within specific timeframes
• Assists patients with organizing their records, making follow-up appointments, and filling their prescriptions.
• Helps patients fill out applications, for example Medical Assistance and SNAP (Supplemental Nutrition Assistance Program). Reviews benefit options, researches community resources and enables members to be active participants in their own health care
• Provides advocacy, patient education and support in accessing community-based and hospital-based programs
• Refers to internal or external services when appropriate
• Maintain regular communication with the patient
• Demonstrates cultural sensitivity and respect for the patient
• Visits the patients in hospital and ER as necessary to facilitate transitions of care
• Prepares reports and documents as needed or requested
• Follows standards of work and consistently maintains department established caseloads and timeframes for case completion. Participates in the refinement of and development of new standards of work.
• Meets regularly 1-1 with the Director of Behavioral Health to review caseload and discuss barriers/challenges and review performance compared to current targets/expectations.
• Documents and reports all quality and patient safety events by recording and adhering to all of Steward Health Care Network's safety reporting guidelines.
• Performs all job functions in compliance with applicable federal, state, local and company policies and procedures.
• Monitors and evaluates effectiveness of care plan and modifies plan as needed. Supports member access to appropriate quality and cost effective care. Coordinates with internal and external resources to meet identified needs of the member's care plan and collaborates with providers.
• Ensures members are engaging with their PCP to complete their care management treatment plan or preventive care services.
• Assists in obtaining benefits for members through community resources when benefits are exhausted or not available.
• Performs other duties as assigned.
• Makes referrals to case managers, as appropriate, and/or refers patient's family to community


• Possess basic knowledge of healthcare system and resources available in their geographical region
• Understanding of language, culture and socioeconomic circumstances and desire to work with diverse population.
• Knowledge of the impact of culture on health, illness, health practices, health beliefs, access to care and participation in treatment and services.
• Understanding of how to advocate and work with patients so that he/she is in the best position to determine what they want and need, promoting the persons' right and capacity to make decisions themselves as well as encouraging and teaching patient self-confidence that will enable them to become self-advocates
• Knowledge of key principles of working with patients with disabilities – self-determination, self-advocacy and person/ family centered individual planning that allow persons with disabilities to live in the safest and least restrictive community based setting.
• Understanding and respect for disability culture and barriers that prevent individuals from receiving appropriate and quality care.
• Dependable and responsible. Open minded, committed and respectful of our members with chronic/complex illness and or disabilities.
• Highly motivated and capable of self-directed
• Outstanding interpersonal skills of foremost importance to interact with families and patients.
• Exceptional organizational skills; ability to multi-task and work independently and part of a team
• Demonstrated ability to prioritize, multitask, and work in a rapidly changing environment with multiple demands.
• Demonstrated oral and written communication skills and is comfortable working with individuals from cultural and linguistically different backgrounds who face barriers in obtaining care and support services.
• Must be able to effectively communicate with patients, family members, case managers, treating physicians and community organizations.
• Ability to utilize tools for the effective documentation of the care management process.
• Ability to travel to attend chapter POD meetings as necessary and to visit select practice sites for meetings with patients, PCPs and other members of the care team
• Attend staff meetings and education offerings both in person and via teleconference as required.
• Proficiency with Microsoft Office applications (i.e. MS Word, Excel, Access, Outlook) and web browsers.
• Must be able to cope with the pressure of time limitations while respecting the needs of the patient and the requirements of the organization/department.
• Ability to take action in solving problems while exhibiting judgment and a realistic understanding of issues; able to use reason, even when dealing with emotional topics.
• Ability to remain open-minded and change opinions on the basis of information, perform a wide variety of tasks and change focus quickly as demands change, and manage transitions effectively from task to task.
• Must possess a strong belief in an organizational culture that encourages valuing and best service excellence practices demonstrated through personal behavior and work ethic.
• Ability to travel, including valid driver's license and auto liability insurance coverage according to company policy.
• Experience with Behavioral Health and or Substance Abuse strongly preferred


Education: Bachelor's degree required
Experience: Minimum of 3 years healthcare, public health, or community-based experience
Certification/Licensure: Current unrestricted Driver's License
Software/Hardware: MS Office Suite
Other: Experience with diverse populations a plus.

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