**Job Summary and Responsibilities** This program will require meeting patients and/or family members in the patients' homes, or other locations in the community. The Continuing Care Community Health Worker is responsible for working in conjunction with an interdisciplinary team in order to improve patient social, behavioral, and mental health needs through outreach and engagement activities. Such activities include telephonic and written communication, as well as in-person opportunities with patients, providers, team members, and community-based organizations. Work may be focused on, but not limited to: 1) establishing effective relationships and guiding the patient/caregiver through the healthcare system, working to eliminate barriers that might otherwise adversely impact patient care/outcomes; 2) providing general education/training designed to promote self-awareness and reinforce/maximize patient/caregiver self-management skills/tools/resources; and 3) facilitating access to support services, community resources and primary care for enrolled patients and tools for self-management support. **Essential Key Job Responsibilities** Relationship Building: + Establishes rapport with patient and caregivers, evaluates patient’s level of health literacy and comprehension, provides information/guidance for an effective care transition and follows up with the recipient to ensure that information is understood by the recipient. + Responsible for building and maintaining a positive working relationship with providers, community-based organizations, social services, and public health for example. + Monitors effectiveness of services provided by external resources and provides timely feedback to the provider/interdisciplinary team. + Acts as liaison with members and families to physicians, staff, community resources, and others + Acts as the liaison between the healthcare team and community resources, may require meeting with community leaders to assist in the process of building and maintaining a working/business relationship between the team and community partner. Patient Care: + Acts as an advocate for the patient and family by locating appropriate community resources to address concerns and reduce risk of hospitalization or readmission. + Coaches patient/caregiver to improve their communication with physicians, nurses, and other members of the healthcare system; assists patient/caregiver in setting, tracking and meeting personal health goals. + Collaborates on patient care issues with an interdisciplinary team, participating in regular and ad hoc case review and Interdisciplinary Team Meetings, and consults with the healthcare team before taking any action that requires a physician order or insurance authorization. + Facilitates patient self-management skills around health status and problem solving for barriers to care. + Meets and/or follows-up with patients via phone and/or clinic visit to coordinate and/or provide timely direct assistance in meeting the self-management goals identified. + Monitor patient progress towards achievement of goals identified in the plan of care and provide ongoing status reports to the healthcare team, escalate issues/barriers as identified. + Model commitment to continuous quality improvement by engaging in quality improvement initiatives and projects, such as identifying and addressing gaps, and by identifying, developing, and testing new practices for improving the outcomes of Members. + Assists with administration of social determinants of health screening activities as assigned. Clerical: + Ensures documentation is accurate, useful and in compliance with company policy. + Review, interpret, and escalate to care team data and/or information from multiple different electronic platforms. + Data entry, scheduling appointments and other related tasks. + Assist patients / caregivers with completion of various forms and paperwork related to identified social need(s). + Other duties as assigned. **Job Requirements** **Required Education and Experience** + High School Diploma/G.E.D. + 1 year experience in a patient-care environment; or 2 years working in a health-related community outreach organization. + Preferred Education: AA or BA. + Preferred Experience: Knowledge and ability to work with electronic medical records; knowledge of healthcare terminology. **Required Licensure and Certifications** + Preferred: CHW Certification **Where You'll Work** Inspired by faith. Driven by innovation. Powered by humankindness. CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation’s largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually through more than 2,300 clinics, care sites and 137 hospital-based locations, in addition to its home-based services and virtual care offerings. CommonSpirit has more than 157,000 employees, 45,000 nurses and 25,000 physicians and advanced practice providers across 24 states and contributes more than $4.2 billion annually in charity care, community benefits and unreimbursed government programs. Together with our patients, physicians, partners, and communities, we are creating a more just, equitable, and innovative healthcare delivery system. **Pay Range** $16.42 - $23.19 /hour We are an equal opportunity/affirmative action employer.