Community Health Worker

Company: Oak Street Health

Title: Community Health Worker

Company Description

Oak Street Health is a rapidly growing company of primary care centers for adults on Medicare in medically-underserved communities where there is little to no quality healthcare. Oak Streetâs care is driven by a unique model that is based on value for its patients, not on volume of services. The company is accountable for its patientsâ health, spending more than twice as long with its patients and taking on the risks and costs of their care. For more information, visit http://www.oakstreethealth.com.

Role Description

Oak Street Health takes a team-based approach to providing outstanding patient care. Our Care Teams, consisting of a Provider, Nurse, MA and Medical Social Worker, build individual relationships across a panel of 500-800 patients. The Care Team is responsible for delivering excellent, high-touch, primary care, and coordinating the care of our patients throughout the healthcare delivery system. We have support team members that assist with specific tasks and/or cases such as Behavioral Health Specialist and Care Coordinators.

Community Health Workers are an important part of our Care Teams. A Community Health Worker is a patientâs advocate or liaison when in a community setting. Building trust and promoting encouragement are two of their key objectives. High levels of flexibility, attention to detail, and problem solving are required to be successful. You will be expected to build relationships with Oak Street Health patients, assist with managing low risk membersâ care plans, perform proactive phone and in-person outreach to our members based on their care needs, support Care Team decision making, participate in weekly care team meetings, and coordinate clinical and complementary services needed to provide a high quality health care experience from Oak Street Health. A Community Health Worker is expected to work within scope of practice. Scope of practice will be determined by the state licensure the individual holds. There is no expected clinical license for this position, thus it is expected that the scope of practice will be limited to the core responsibilities listed below.

Core Responsibilities Include:

• Manage low risk referrals defined by care management program (Medical Social Work) & collaborate with social worker on action plan

• Develop trusting relationships with patients by providing support and advocacy to help achieve health goals

• Meet with patients in patient centered and patient preferred locations (e.g., center, facility, home, community setting)

• Promote goal setting with patients enrolled in care management. Goal definitions are agreed upon by the care team

• Drive engagement with high risk individuals (e.g., completed specialty appointments, adherence to Post discharge visits) may include accompaniment to appointments

• Assist completion of applications to access eligible benefits

• Wellness checks in home, participate in remote monitoring program education on individuals with specific health conditions

• Provide approved health screenings, referrals and information

• Deliver health education presentations in the areas where OSH has provided competency training to the CHW

• Facilitate communication between all identified parties on behalf of the patient involved in care, as needed (e.g., family members, care givers, medical providers, community-based organizations)

• Maintain HIPAA standards and confidentiality of protected health information

• Document interactions with patients in medical record

• Community Health Worker is expected to work within scope of practice and should plan to spend about half their time outside of the center (in the community, facilities, or at patient homes); this means having a mode of transportation to do so is required

• Other duties as assigned

What weâre looking for

Weâre looking for motivated individuals with:

• A problem-solving orientation and a flexible and positive attitude

• Minimum of 1 year of experience in healthcare, community-based, or social work environment is preferred

• Community Health Worker certification is a plus

• Experience utilizing electronic medical record systems

• Knowledge of community resources and resource navigation

• Experience working on a multidisciplinary team preferred

• Proficient PC skills

• Fluency in language that is commonly spoken in the community is necessary. Most often this will include Bilingual English/Spanish

• Travel to community required

• US work authorization

• Someone who embodies being âOakyâ

What does being âOakyâ look like?

• Radiating positive energy

• Assuming good intentions

• Creating an unmatched patient experience

• Driving clinical excellence

• Taking ownership and delivering results

• Being scrappy

Why Oak Street?

Oak Street Health offers our coworkers the opportunity to be at the forefront of a revolution in healthcare, as well as:

• Collaborative and energetic culture

• Fast-paced and innovative environment

• Competitive benefits including paid vacation and sick time, generous 401K match with immediate vesting, and health benefits

Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply to oakstreethealth.com/careers.