Provides tailored health education, social support, connecting to health care and community based resources and advocates for patients and their family, with a focus on specific diseases, conditions, and populations that experience health disparities. Delivers and facilitates evidence based programs and interventions to prevent and improve management of chronic disease. Uses a specialized protocol and curriculum to provide assessments and education to patients and program participants. Assists with data collection and interpretation to understand patient and intervention-related outcomes. Plays a key role in building individual capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, health education, informal counseling, social support, and advocacy. Works collaboratively with other health care and community-based providers to improve patient health outcomes and reduce racial, ethnic, and economic disparities in those outcomes.
ESSENTIAL FUNCTIONS: Our Trinity Health Culture: Knows, understands, incorporates & demonstrates our Trinity Health Mission, Values, Vision, Actions & Promise in behaviors, practices & decisions. Work Focus: Provides high-value services to patients with complex social and health needs, in clinical and community-based settings. Delivers evidence-based programs and interventions with fidelity to patients assigned to their caseload. Assists with identifying, engaging, and enrolling individuals that may be eligible for CHW interventions and evidenced-based programs. Conducts and interprets assessments to learn patients’ social needs, reduce barriers and connect to appropriate resources and services. Facilitates access to health and human services for patients through in-person interactions and coaching. Provides culturally appropriate support Community Health Worker II and follow-up to encourage behavior change and achieve health-related goals. Shares insight and expertise, such as patients’ customs/beliefs with providers and works collaboratively to promote culturally appropriate services.
Process Focus: Utilizes multiple system applications for caseload management, data collection, and reporting. Uses electronic health record and intervention-specific protocols for care coordination and documentation. Uses applicable resources, services, and processes to complete relevant referrals and applications in a timely manner. Incorporates basic knowledge of Trinity Health policies, practices & processes to ensure quality, confidentiality & safety are prioritized. Demonstrates knowledge of departmental processes & procedures & ability to readily acquire new knowledge. Collaborates on performance improvement activities as indicated by program outcomes & patient experience.
Communication: Employs effective & respectful written, verbal & nonverbal communications; Develops an environment of mutual confidence & trust through collaborative relationships; Effectively communicates goals, standards, program expectations, service performance & how the work serves Trinity Health objectives. Serves as a liaison between health care and social service providers and patients to improve communication and coordination of services. Provides support to patients via phone and in-person interactions at the patient’s home, in the community, or at the clinic setting.
Environment: Performs work in a caring, collaborative & safe manner that complies with regulatory standards. Maintains a safe, functional & organized workspace environment. Stewards productive use of resources (e.g., people, financial, equipment, supplies, materials) to achieve assigned commitments, experiences & quality standards. Accountable for continuous role-based self-development & leadership growth. Supports the professional growth of team members. Self-monitors & initiates corrections and/or seeks assistance or guidance when needed. Maintains a working knowledge of applicable Federal, state & local laws/regulations, Trinity Health Integrity & Compliance Program & Code of Conduct, as well as other policies, procedures & guidelines to ensure adherence in a manner that reflects honest, ethical & professional behavior & safe work practices.
MINIMUM QUALIFICATIONS:
Additional Qualifications (nice to have): Maintains CHW Certification per Trinity Health guidelines and/or State sanctioned guidance.
Our Commitment
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.