This position will be focused on high needs Chronic Kidney Disease (CKD) and End-Stage Kidney Disease (ESKD) populations that face multiple challenges, from accessing resources to adhering to a physician’s treatment plan. The CHW will work as an extension of the clinical care team, specifically under the guidance of a renal nurse care manager. The individual taking this role will manage his/her caseload through in-person, telephonic and electronic means of communications and coordination. This position is a market-based position.
- Works under the guidance of physicians and/or a nurse care manager.
- Follow-up with health management plans and goals.
- Establish positive, supportive relationships with participants and provide feedback.
- Conduct an initial triage assessment to help align patients with the most appropriate program in accordance with program guidelines.
- Documents their activities in the care coordination platform, including care plan activities conducted.
- Engages with patients who need assistance with self-care needs in addition to what a nurse care manager can provide via phone, such as:
- Address language and cultural barriers to care management and self-care.
- Coach and guide the patient to meet both personal and clinical goals.
- Schedules provider appointments on behalf of their patients.
- Accompanies patients to their appointments when needed.
- Reminds patients of their upcoming appointments.
- Helps patients access community and government-based services, including possibly filling out paperwork for the patient.
- Helps to teach the caregiver about symptom response plans.
- Arranges transportation.
- Facilitates closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testing.
- Assists patients with enrolling to access educational videos.
- Participates in the integrated care team meetings.
MEASURES OF SUCCESS
- Patient Engagement
- Care Setting Transitions
- Experience working with Medicare, Medicaid or Special Needs populations.
- Medical Assistant, Licensed Practical Nurse, Engagement Specialist or Community Health Worker Experience.
- Ability to connect with people and understand the challenges they face.
- Ability to use a range of outreach methods to engage individuals and groups in diverse settings.
- Well connected to the community and resources within the community they will serve.
- Effective written and verbal communication skills demonstrating respect and cultural awareness during interactions with clients.
- Ability to travel throughout the assigned region and comfort with conducting home visits (50-75% same day travel).
- Experience working with patients with chronic and behavioral health needs.
- Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Physicians and Registered Nurses.
- Proven experience with engaging patients in making healthy behavior changes.
- Proven skills in navigating the health systems and making necessary linkages in order to meet specific needs.
- Can speak other language(s).
- Experience working with Electronic Medical Records and other documentation platform.
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Somatus, Inc. provides equal employment opportunity to all individuals regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, or any other characteristic protected by state, federal, or local law. Further, the company takes affirmative action to ensure that applicants are employed, and employees are treated during employment without regard to any of these characteristics. Discrimination of any type will not be tolerated.