Job Summary and Responsibilities

The role of 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 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, assesses patient’s level of health literacy and comprehension, provides information/guidance for an effective care transition and ensures that information is understood by the recipient.  Responsible for building and maintaining a positive working relationship with Providers, including, but not limited to, interactions within Provider offices, communication over the phone, and through digital means such as email and fax.  Acts as an advocate for the patient/family by locating appropriate community resources to address concernsand reduce risk of hospitalization.  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  Escalates any internal and external customer concerns to the interdisciplinary team and/or Supervisor

Patient Care Acts as an advocate for the patient and family by locating appropriate community resources to addressconcerns and reduce risk of readmission. Coaches participant/caregiver to improve their communication with physicians, nurses, and other members of the healthcare system; assists participant/caregiver in setting, tracking and meeting personal health goals.  Collaborates on Member care issues with interdisciplinary team, participating in weekly and ad hoc case review and Interdisciplinary Team Meetings, and consults with Nurse Care Manager and/or the Social Worker before taking any action that is clinical in nature.  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. Document activities, discussions, plans, and results in various formats and health records  Review, interpret, and escalate to care team the data and/or information in multiple different electronic platforms

May also be required to meet patients and/or family members either in the community, at clinic, home, or other

locations.

Job Requirements

Required Education and Experience:
High School Diploma or equivalent
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"
Certified Medical Assistant or LPN

Required Minimum Knowledge, Skills, Abilities and Training:
Ability to perform EKGs, draw blood and administer injections.
Ability to effectively communicate to staff and patients.
Demonstrated knowledge of examination, diagnostic and treatment room procedures.
Thorough knowledge of the meaning and use of medical terminology and abbreviations.
Demonstrate sound judgment and composure with the ability to take appropriate action in questionable or emergency situations.
Maintains a positive, caring attitude towards patients.
Good computer skills using a medical management application.
Possess a strong work ethic and a high level of professionalism.

Where You'll Work

CHI Memorial Medical Group (Mountain Management Services), a member of CommonSpirit Health, is a leading provider of comprehensive office management services for Memorial Health Partners and affiliated physicians in Southeast Tennessee and North Georgia. Our award-winning, faith-based organization is dedicated to supporting the delivery of exceptional healthcare in the region. We are proud to be consistently recognized for excellence by organizations like U.S. News & World Report, PINC AI™, CMS, Healthgrades®, Leapfrog, and as one of the Best Places to Work in Tennessee. We are honored to be your trusted ally in health, dedicated to serving our community with compassion and excellence.

Total Rewards

Depending on the position offered, CommonSpirit Health offers a generous benefit package, including but not limited to medical, prescription drug, dental, vision plans, life insurance, paid time off (full-time benefit eligible team members may receive a minimum of 14 paid time off days, including holidays annually), tuition reimbursement, retirement plan benefit(s) including, but not limited to, 401(k), 403(b), and other defined benefits offerings, as may be amended from time to time. For more information, please visit our Total Rewards

Unless directed by a Collective Bargaining Agreement, applications for this position will be considered on a rolling basis. CommonSpirit Health cannot anticipate the date by which a successful candidate may be identified.