Community Health Worker, Care Management - Hybrid NYC

Summary of Position

Serve as a trusted community liaison to engage members in improving their overall health, well-being, and access to care through culturally competent outreach, education, coaching, and support. Partner closely with nurse and social work care managers and interdisciplinary care teams to identify member needs, reinforce care plans, and address barriers to achieving health goals. Conduct outreach through a combination of telephonic, virtual, community-based, and in-person interactions, including meeting members in provider offices, community settings, and other appropriate locations. Build strong, supportive relationships with members to promote preventive care, wellness, self-management, healthy behaviors, and engagement with recommended services. Provide health education, motivational coaching, and care navigation to empower members to make informed decisions and actively participate in their healthcare. Collaborate with primary care providers, behavioral health providers, community organizations, and other stakeholders to coordinate services and improve member outcomes. Document all member interactions, interventions, and outcomes accurately and timely in accordance with organizational policies and regulatory requirements. Identify members who may benefit from escalation or additional clinical support and facilitate this via communication and coordination with the care management team. Participate in outreach events, wellness initiatives, and community engagement activities that support population health and member experience. Support targeted programs for specific member populations, such as employer groups, union populations, high-risk members, or other strategic initiatives, while maintaining flexibility to serve evolving organizational priorities. Contribute to quality improvement efforts by identifying trends, barriers to care, and opportunities to enhance member engagement, health outcomes, and program effectiveness.

Principal Accountabilities

• Work collaboratively, as a critical component of the care management team to facilitate wellness, self-management, and prevention, in addition to non-clinical administrative tasks on behalf of members.
• Perform member telephonic and in-person outreach for program enrollment with the goal of retaining members in the Care Management Program.
• Perform in-person member visits in community settings, such as their home, Neighborhood Care Centers, Community Agencies, hospitals and physician offices to introduce care management programs and validate member contact information.
• Triage cases and assign receipts to appropriate teams.
• Communicate and/or respond to inquiries from providers, facilities and members.
• Enter and maintain documentation in electronic record, meeting defined timeframes and performance standards.
• Provide phone queue management for both incoming and outgoing calls.
• Perform other related projects and duties as assigned.
• Under the direction of a Care Manager, manage caseload and update care plans collaboration with the clinical team.
• Support care interventions including making doctor's appointments, health coaching, referrals to internal and external resources, assist with transportation issues.
• Identify and address support needs for Transitions of Care.
• Leverage motivational interviewing skills and a member-centric approach to identify members' needs, prioritize and support care plan.
• Perform a wide range of research and educational outreach activities to encourage healthy behaviors, such as outreaching to identified members who need a primary care provider or who may have gaps in care related to recommended tests or provider visits and facilitate gap closure and receipt of evidence-based care.
• Adhere to processes for collecting member-specific clinical and demographic data from providers and other entities as required by clinical staff.
• Support communication and coordination with delegated entities, as necessary.
• Coordinate directly with community-based organizations and agencies to identify available and/or alternative resources for a wide range of concerns, including home safety, financial assistance, caregiver support and transition assistance.
• Actively participate in assigned committees and projects.
• Additional tasks and duties as required.