Job Description

Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together we will achieve our mission to enhance the health and well-being of the people and communities we serve.

General Summary:
This position reports to the AHNJ Manager of Population Health, with accountability to accomplish targeted outreach to plan members who have clinical care gaps, to assess and provide resources for social determinants of health (SDOH) challenges. Assessment & intervention examples include addressing gaps due to a lack coordination of services. This includes discussions to assess barriers, such as issues with health literacy, access to healthcare, need for available low-income resources, and solving for transportation limitations. These needs have been identified primarily within Camden, Burlington, and Gloucester counties. A Community Health worker serves as a connection between members and caregivers, with the health plan & healthcare providers, and with community resources to promote health equity and improve member outcomes.

Key Responsibilities:

Conduct outreach to members identified with clinical gaps in care and perform SDOH assessments to determine applicable resource needs.

Assist members, who do not have an identified primary care provider (PCP), with selection of a PCP, and helping the member to access PCP care. This includes securing an appointment and potentially accompanying the member to the appointment as needed.

Focus on relationship with PCP office to secure necessary prescriptions and orders for further evaluation.

Educate members and families on insurance benefits and programs and on community resources.

Generate internal referrals to clinical team including nurse health coaches and social workers.

Identify community services for members and build relationships with local organizations and health systems partners

Coordinate referrals to external community social agencies or services such as prescription assistance programs.

Supports patients in understanding and carrying out provider recommendations.

Document all interactions and interventions offered.

Track monthly number of member referrals, PCP visits, and clinical gap closures.

Motivate members to be active and engaged participants in their health.

Participate and attend member events and health expos to assist in member education.

Perform other duties as assigned.

Qualifications:

·Education: high school diploma or equivalent

Experience: Minimum one-two year relevant experience or volunteer work in community outreach, public health, health education, or social services.

Preferential experience working with vulnerable populations, including seniors, with a focus on addressing social determinants of health

Required: Driver’s license and car insurance

Skills:

Proficiency in Spanish, written and verbal

Strong interpersonal, communication, and organizational skills

Proficiency in documentation and use of care management systems

Knowledge of community resources and social service systems

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