Clinical Community Health Worker - Transition of Care MA

COMMUNITY HEATH:

Community Health is a primary care network that provides nationally-recognized programs, a focus on wellness, dental, behavioral health and pediatric specialties, walk-in Express Care, a culture of community and quality health care that almost everyone, insured or uninsured, has come to depend on. As an equal opportunity employer, we offer a team-oriented, collaborative work environment for close to 400 employees at eight different locations in Rutland and southern Addison counties. 

ABOUT THE ROLE:

The Clinical Community Health Worker (CCHW) works collaboratively with the Transitional Care Manager to support care coordination and initiate timely outreach for patients recently discharged from inpatient settings or the emergency department (ED). The CCHW is responsible for assisting patients and their families in navigating and accessing community services, resources, and promoting healthy behaviors. Additionally, the CCHW will facilitate scheduling appointments with primary care providers across the organization. This role provides social support, informal counseling, and advocacy on behalf of individuals and the broader community health needs. Furthermore, the CCHW will implement procedures to address identified care gaps, as well as deliver personalized outreach and follow-up to patients.  

FUNCTIONS OF THE POSITION: 

• Care Coordination and Navigation: 
  • Collaborate with Transitional Care Manager to review in-patient and emergency department discharge lists daily. 
  • Schedule discharge follow-up appointments with respective primary care providers across the organization. 
  • Facilitate communication between patients and health care teams. 
  • Document outreach efforts in EMR and update Aledade App as appropriate. 
  • Create a working spreadsheet of all discharged patients to track and monitor progress.