Job description

JOB SUMMARY:
Reporting to the Care management leader and working under the direction of the care manager, the Care Coordinator/Community Health Worker supports implementation of the patient’s integrated care plan and works towards resolution of patient needs/barriers. The Care Coordinator/Community Health Worker facilitates communication between patients, their families, caregivers, providers, and other members of the health care team. The care coordinator/community health worker carries out delegated functions related to disease states and other conditions that have been deemed to be part of the scope of practice for unlicensed staff members. Their focus is to offer individualized assistance to patients, families and caregivers in order to help overcome health care system and community barriers and help facilitate consistent and timely medical care across the continuum of care. Care coordinators/community health workers function as members of the integrated care delivery team.

RESPONSIBILITIES:

• Perform Health Risk Assessments.
• Provide general care management orientation to patients and communicate the goals and objectives of the program.
• Provide assistance for patients referred to/from providers, care managers, and from other points of entry.
• Assist with scheduling medical and specialty appointments. Provide reminder phone calls for appointments and/or follow-up calls post appointment.
• Contact patients to facilitate continuity of care and escalate issues to Care Manager.
• Compile and distribute educational material per patient need in consultation with Care Manager.
• Assist patients with adherence to existing self-management goals or development of new goals (in collaboration with Clinical Staff).
• Assist in identifying individual and/or community needs which encourage healthy lifestyles and

environments (i.e., community resources, transportation assistance, exercise programs, etc.).

• Interact with the multidisciplinary team on behalf of the patient to resolve barriers. Communicate outcomes to patient/family/caregivers.
• Assist in the collection and assembly of quality improvement information for the purpose of tracking and trending.
• Participate in cross-functional team meetings aimed at improving patient outcomes or operational processes.
• Regularly participates in care team huddles with care managers to identify priorities, tasks and interventions.
• Maintain timely and appropriate documentation on patient interactions in the care management system.
• Develop and maintain excellent working knowledge of common chronic conditions and seek information as part of continuous learning.
• Provide disease specific and preventive care patient education.
• Ensure timely follow up with provider post hospitalization / emergency room visit.
• Retrieve discharge summaries and copies of medical records.
• Make home and facility visits, if necessary, to ensure patients are following their plan of care.
• Perform population management activities as assigned

**duties will vary depending on level of experience and licensure status
QUALIFICATIONS:

• Bachelor’s or associate’s degree in health or social services field or equivalent work experience in healthcare (3 years) preferred
• MA/CNA/CHW experience preferred
• Care coordinator certification desirable

Now Accepting Applications for a Care Coordinator/Community Health Worker- Kingston Location
Are you looking for an opportunity to become part of a great team?
The Family Health Center of Southern Oklahoma is a Community Health Center that focuses on wellness, collaboration, and excellence. Providing care for all patients whether they have insurance or not, we offer comprehensive services like medical, dental, prescription and mental health services, striving to treat the whole body.
FHCSO is looking for someone to join our team of amazing people. This position is for a Care Coordinator/Community Health Worker.
Why Should You Apply?

• Great Pay
• Exceptional Benefits including healthcare and 401k
• Paid Time Off
• Great work environment
• Holidays and weekends off

Job Type: Full-time

offroadmanagementgroup.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, offroadmanagementgroup.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, offroadmanagementgroup.com is the ideal place to find your next job.