Community Health Worker- Immigrant Populations Focus

POSITION SUMMARY: The CHW will focus on working with immigrant and refugee communities. The CHW will work with the external organizations serving the immigrant population to connect community members to health care and social service agencies as needed. The CHW will schedule appointments, close gaps from SDOH assessment, make referrals as needed to other entities, ensure follow-up for services as needed, and communicate with teams to develop an holistic plan of care and follow up. Serves the patient and medical teams by providing excellent patient care and establishing close points of contact between medical and social teams. Create clear lines of communication, closing care gaps, and decreasing social determinants of health through the circulation of important information and case management of referrals and follow-up. Perform the duties required to act as a community liaison. Also acts as a liaison between primary care medical providers, social service agencies, community health departments, hospital systems, and local community organizations. POSITION QUALIFICATION REQUIREMENTS: Education: Requires high school graduate or equivalent, and successful completion of Community Health Worker course. Required Education and Experience : Knowledge of and/or is part of the community served Ability to read, write, and speak English required. Ability to read, write, and speak another language required. Ability to read, write, and speak Dari and/or Pashto strongly preferred. Experience in community work (especially Promotor(a) programs), education, health care, or related field preferred Reliable transportation, valid driver's license, and insurance required TB test must be current Skills and Abilities (which may be representative but not inclusive of those commonly associated with this position). Ability to communicate easily with others, including demonstrating active listening skills Takes initiative Good judgment in work. Knowledge of immigrant and refugee process and/or programs. Knowledge of health center protocols, policies, and procedures. Highly proficient computer skills with Outlook, Word, Excel, and experience with an EMR. Willingness to promote health and maintenance programs. Demonstrates initiative, flexibility, and excellent organizational skill. Strong oral and written communication skills which demonstrate excellent customer service and teamwork. Ability to create a perform work activities in a safe and healthy manner in community environments and amongst high risk/vulnerable populations. Ability to maintain a professional attitude and demeanor at all times. Ability to keep information confidential. Transportation Requirement: Must possess a valid driver's license and automobile with insurance coverage as required by the State of Missouri. License(s)/Certification(s) Required: CPR Certification FUNCTIONS OF THE JOB Essential Functions: Assist in accessing primary medical, dental, and behavioral health care for community members. Conduct SDOH screening utilizing the PRAPARE assessments to determine SDOH needs annually or more frequently, if change in health status. Provide care coordination, which may include but is not limited to facilitating care transitions, supporting the completion of referrals, and providing or confirming appropriate follow-up. Make referrals and connections to community resources to help individuals and families meet basic social needs. Responsible for the implementation of the goals and objectives set forth and adopted by Affinia Healthcare. Provide outreach, education, referrals, and follow-up, as needed primarily for the purposes of closing gaps from social determinants of health. Assess patients/community members for social determinants of health, and develop plan with patient to include referrals to external organizations and support. Complete community referrals based on PRAPARE assessment results and social needs. Enhances communication between internal medical departments and external medical, social, and various community referral agencies. Responds to the social needs of clients/patients; telephonic, virtual, and in person communication. Facilitates appointments and appointment follow-up within Affinia Healthcare, and with community agencies. Assists with the scheduling of specific patient appointments, makes reminder appointment calls, and contacts patients who have missed scheduled appointments when necessary. Collect and document data using electronic health record, and provide timely follow-up reporting. Obtains medical documents for transitions of care. Responds to General Practitioner queries in a professional and timely manner. Effectively works with other health care team members to ensure coordination of care. Addresses the questions and concerns of patients, families, and staff members. Coaches and supports patients to develop and accomplish SMART social and health goals. Compiles and coordinates patient feedback and information for the primary care team. Communicates with providers about patient's experiences and barriers to self-management and access to care. Assists with enhancing communication between hospitals and primary care providers. Completes all reports in a timely fashion. Performs other duties as assigned Marginal Functions Attend and actively participate at required meetings. Assists in preparation of monthly reports regarding case management/community health worker activities. Assist with the implementation of new procedures and processes. Supervises: None NOTE: Affinia Healthcare is a Covid-19 Vaccine Mandated Employer. All employees of Affinia Healthcare are required to be vaccinated for Covid-19. NOTE: SMOKING IS PROHIBITED IN THE WORK ENVIRONMENT NOTE: ALL APPLICANTS MUST PROVIDE CONTACT INFORMATION FOR THREE REFERENCES AN EQUAL OPPORTUNITY SERVICES PROVIDED ON A NON-DISCRIMINATORY BASIS