Community Health Worker, ID Program

Position Summary

The Community Health Worker will conduct culturally appropriate care coordination, health education and outreach activities in the health centers and within the community. The Community Health Worker will assist patients to access the variety of social and medical services they need to maintain their health. The Community Health Worker will collaborate with the ID Care Team and the patients’ primary care physicians to promote health and wellness and contribute to the goals and objectives of the patients’ care plans.

Key Functions & Responsibilities

• Build trusting relationships with patients and families while providing encouragement, motivational interviewing, goal setting, and health education.
• Conduct patient intakes and assess medical, social, financial, insurance, and other barriers that affect access to and adherence with care.
• Manage an assigned caseload and provide follow-up from initial identification through resolution or closure.
• Coordinate internal and external medical appointments, referrals, and care transitions.
• Support HIV care, including re-engaging patients who are out of care or at risk of falling out of care.
• Support PrEP referrals and tracking in collaboration with the clinical team and community partners.
• Provide HIV, STI, and general health education tailored to patients’ needs.
• Assist patients with applications, enrollment, renewals, and recertification for Medicaid, Medicare, Maryland Health Connection, MADAP, pharmaceutical assistance programs, and other benefits or financial assistance programs.
• Review insurance coverage, medical needs, medications, and financial eligibility to help patients identify appropriate options.
• Address medication-access issues, including prior authorizations, appeals, pharmacy coordination, emergency fills, coverage gaps, travel overrides, and insurance transitions.
• Coordinate access to injectable medications, including prior authorization, pharmacy communication, clinic delivery, and resolution of delays or denials.
• Manage pharmaceutical assistance and manufacturer programs, including Gilead Advancing Access, ViiV Connect, manufacturer co-pay programs, and other medication assistance resources.
• Serve as a liaison among patients, providers, pharmacies, insurance companies, health departments, and community agencies to resolve barriers to care.
• Coordinate care for newly diagnosed patients with local health departments and support timely linkage to appropriate services.
• Follow up on referrals to Disease Intervention Specialists (DIS) and other public health programs.
• Connect patients and families with social and enabling services, including transportation resources, food assistance, housing, legal services, energy assistance, disability/SSI resources, childcare, employment and job-training resources, medical equipment, and other social determinants of health resources.
• Assist patients in obtaining durable medical equipment, such as wheelchairs and walkers.
• Help patients complete application forms related to their health care needs.
• Serve as a patient advocate and liaison with community organizations, schools, government agencies, hospitals, support programs, and other service providers.
• Maintain current community resource information and build relationships with organizations that support patient needs.
• Participate in case conferences, HIV/ID care team meetings, coalition and community work groups, and other organizational meetings as requested.
• Maintain and update HIV/ID program patient lists and other tracking systems.
• Document all patient contacts and care-management activities accurately in the EMR and other required systems within 24 hours of contact.
• Provide language support or translation for patients, as appropriate.
• Collaborate with CCI staff and community partners to promote equitable, accessible, and coordinated care.
• Maintain positive working relationships with patients, visitors, staff, and community partners while effectively communicating CCI’s mission.
• Travel between CCI sites as needed to provide coverage or support.
• Perform other duties as assigned.

MINIMUM REQUIREMENTS

• High school diploma or equivalent; associate or bachelor’s degree preferred, or equivalent relevant experience.
• Successful completion of a Community Health Worker training program and/or current CHW certification; certification must be obtained within 90 days if not already certified.
• HIV PrEP Navigation Certification preferred or ability to obtain.
• One (1) to two (2) years of experience in a community-based, healthcare, social-service, or related setting preferred.
• Knowledge of HIV, PrEP, STIs, healthcare systems, and community resources.
• Experience with insurance enrollment, benefits navigation, medication assistance, or care coordination preferred.
• Experience working in multicultural and community-based environments.
• Strong understanding of and connection to the communities served.
• Strong communication, listening, advocacy, organization, and interpersonal skills.
• Ability to establish and maintain positive working relationships with patients, families, CCI staff, healthcare providers, insurers, pharmacies, and community organizations.
• Ability to provide emotional support, encouragement, and motivation to patients.
• Computer proficiency and experience with electronic medical records (EMR); proficiency with eCW preferred.

WORKING CONDITIONS

• This is based physically on-site position and may require travel between CCI Health Services locations.
• Work may involve prolonged periods of sitting, standing, bending, and computer use.
• Must have the ability to lift up to 15 pounds.
• Clinical environment with potential exposure to infectious body fluids and other potentially hazardous materials; appropriate safety precautions and protective equipment are required.
• Work may involve stressful situations and interaction with patients experiencing complex medical and social needs.
• Reasonable accommodations may be made in accordance with the Americans with Disabilities Act, provided they do not create an undue hardship or significant health or safety risk.

Why work at CCI?

• Extensive benefits plan including PTO
• 403B Retirement Plan
• Tuition reimbursement opportunities
• Continuing education assistance; can be used toward obtaining certifications, renewal of certifications, or possible conference attendance.
• Our providers are insured for malpractice under FTCA.

Equal Employment Opportunity (EEO)

CCI Health Services does not unlawfully discriminate based on race, religion, color, national origin, citizenship, ancestry, physical or mental disability, legally protected medical condition (cancer related or genetic characteristics or any genetic information), marital status, sex, sexual orientation, gender identity, gender expression, pregnancy, age (40 or older), military and/or veteran status or any other basis protected by federal or state law. All personnel decisions are to be administered in accordance with this policy and in compliance with applicable federal and state law, including, but not limited to, decisions regarding recruitment, selection, training, promotion, compensation, benefits, transfers, lay-offs, tuition assistance, and social and recreational programs.

The CEO & President of CCI and all managerial personnel are committed to this policy and its enforcement. Employees are directed to bring any violation of this policy to the immediate attention of their supervisor, Human Resources, or the CEO & President. Any employee who violates this policy or knowingly retaliates against an employee reporting or complaining of a violation of this policy, shall be subject to immediate corrective action, up to and including termination of employment. Complaints brought under this policy will be promptly investigated and handled with due regard for the privacy and respect of all involved.