Job Description

This is a teleworking position with the expectation to work in various community settings in Baltimore City and Baltimore County.

Who We Are

The Coordinating Center (The Center) has 40 years of experience supporting children, youth, adults and seniors with complex medical needs and disabilities statewide. Deeply committed to a person-centered approach and philosophy, The Coordinating Center helps individuals of all ages and abilities achieve optimal quality health, affordable healthcare and meaningful community life. Over the past four decades, we have become an industry expert in the delivery of person-centered, community-based care coordination services and population health.

Who You Are

We are looking for people who have a passion for helping others in your community, and who align with our mission, vision, and values as a nonprofit organization. If you have experience in healthcare and/or public health, this might be the organization you have been searching for! We look for collaborative and creative minds, self-managing organizational skills, and the desire to challenge and grow professionally. Specific qualifications are:

• At least one year of a human service/healthcare related bachelor’s degree coursework required; a bachelor’s degree preferred.
• An active Community Health Worker (CHW) Certification in Maryland.
• A minimum of two (2) years of health care industry or public health experience.
  

What You Will Do

The Community Health Worker (CHW), in collaboration with the UMMS Population Health Care Management Team, will outreach to and engage with clients to provide Social Determinants of Health (SDoH) screenings, resource access, and care coordination to address the identified clients’ SDoH needs and to support program enrollees' self-management interventions related to health. The CHW will work closely with medical providers, primary care teams and other agencies to improve client care. The CHW will assist in the identification, referral, and follow-up of resources to address gaps and barriers related to SDoH for the UMMS CORE Program’s targeted population of clients at higher risk for poor health outcomes related to SDoH. The CHW will be fully integrated into the workflow and complementary programs included within the UMMS Population Health Care Management Team’s services and will work seamlessly with the designated provider practices.

Essential Responsibilities

• Demonstrates knowledge of the population served and manages an assigned caseload of clients who have low to moderate risk under direct supervision and/or use of appropriate screening and management tools.
• Builds trust with clients and their families, while providing general support and encouragement, through the conduction of outreach efforts, home visits, and follow-ups that focus on chronic disease management, preventive care, and social determinants of health.
• Demonstrates understanding and sensitivity to serving a culturally diverse population while respecting privacy and confidentiality.
• Promotes a holistic approach to identifying and meeting client needs using motivational interviewing and trauma informed care techniques when identifying issues and goals and communicating with clients.
• Guides individuals to play an active and informed role in their self-advocacy and care management.
• Provides individual assistance and support to clients in the development of health care strategies and identification of community resources to address health disparities and barriers to care.
• Participates in the visual inspection of the physical condition of the client’s house, when warranted, to identify factors that may be detrimental to maintaining a safe, healthy, and comfortable living environment.
• Promotes access to resources, assists in addressing barriers to care, and facilitates coordination of services across care settings to improve client’s ability to engage with primary care and to adhere to treatment plans with the goal of helping to reduce avoidable utilization.
• Acts as a client advocate and liaison between the client/family and community service agencies, providing referrals for services to community agencies as appropriate.
• Implements interventions for the CHW within the care plan established by the care team.
• Works closely with the UMMS Population Health Care Management Team to facilitate interdisciplinary collaboration and continuity of care across care settings.
• Provides care coordination across multiple settings, including medical office, hospital, and outpatient services.
• Facilitates client’s scheduling of health care provider appointments and may provide appointment reminders, support, and outreach for follow up regarding missed appointments.
• Promotes compliance with UMMS CORE Program work plan through a robust understanding of contract requirements and deliverables and active participation in metrics development, data collection, and program reporting.
• Works autonomously utilizing the Coleman model as the basis for client interactions.
• Promotes sustainability and success of UMMS CORE Program through active participation in training, team education, and meetings to facilitate client and community engagement.
• Achieves monthly, quarterly, annual enrollment goals and other programmatic metrics as defined annually.
• Effectively communicates in writing to document client information and progress, recording care coordination information in The Center’s and UMMS’s care management information systems no later than 24 business hours after client contact.
  

What we look for in qualified candidates:

• Strong motivational interviewing and critical thinking skills with expertise in relationship building, community resource development, identifying barriers, and the person- centered care philosophy.
• Must have reliable transportation to travel between facilities and community locations as needed.
• High knowledge of the social determinants of health (SDoH) and local population, demographics, assets, and needs combined with high competence in linking resources to address SDOHs.
• Ability to work in a team situation maintaining effective working relationships with other professionals and a clear understanding of CHW scope of practice.
• Knowledge of private insurances and Medicare, Medical Assistance and Managed Care Systems and services.
• Ability to identify problems, develop a course of action and follow through to resolution under the support of the Interdisciplinary Care Team.
• Ability to multitask at any given time while maintaining strong attention to detail.

Why Join Us

We are proud to offer a comprehensive and award-winning benefits package including medical FSA/HSA plans, dental, vision, matching 403b, and short term/long term disability options.

We facilitate ongoing conversations about professional development opportunities and invest in our coworkers by providing funds to use for professional development, and funds for furthering education. We also encourage collaboration within our different councils and committees to get involved with other coworkers across the organization.

The hourly rate for this position is $24.75 and comes with all of our full time benefits including paid mileage for all travel.

The Center is an Equal Opportunity Employer that does not discriminate on the basis of actual or perceived race, creed, color, religion, alienage or national origin, ancestry, citizenship status, age, disability or handicap, sex, marital status, veteran status, sexual orientation, arrest record, gender identity, genetic information, or any other characteristic protected by applicable federal, state or local laws. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, coworker activities and general treatment during employment. We believe we are stronger together. It’s what makes us exceptional in achieving our mission and drives us to deliver culturally competent and effective care coordination services.

Job Tags

Similar Jobs