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Complex Care Outreach Worker in Philadelphia, PA at Public Health Management Corporation

Date Posted: 10/24/2018

Job Snapshot

Job Description

A Complex Care Outreach Worker is sought to support a Complex Care Management Team through an integrated approach to care management and community outreach. The Outreach Worker will report to the RN Complex Care Manager and will be responsible for the identification and engagement of high-risk Health Network patients in the community. The position will be responsible for connecting identified patients to the Complex Care Management Team and to initiating targeted outreach in Philadelphia to patients that have had a lapse in care, especially persons with specified chronic conditions. The Outreach Worker will also work closely with staff across six PHMC FQHC sites and with stakeholders in the community to engage and link patients to Heath Network services. The position will additionally be responsible for assisting patients in understanding and advocating for their health needs, and navigating and accessing health and social services relevant to their primary care. The full-time community outreach position will require frequent, local travel and may include home visits and program screenings, where appropriate. It may also include home visits and escorting patients to appointments, as necessary. This employee will be required to drive a mobile medical van and will work in the mobile van as well as in an FQHC setting.

Responsibilities:

  • Work in the community and with local stakeholders (e.g. hospitals, social services) to locate and engage Complex Care Management patients;
  • Provide outreach to patients by eliminating social, cultural, linguistic, and educational barriers;
  • Ensure that patients obtain timely access to appropriate Health Network services by promoting and modeling advocacy skills;
  • Engage patients in the community, at home or at medical and social service agencies to better connect them to care;
  • Ensure contacts with identified Complex Care Management patients are made and documented;
  • Work closely with the Complex Care Management Team to help ensure patients have comprehensive and coordinated care;
  • Provide consistent communication to the Complex Care Management Team to evaluate patient;
  • Provide referrals for social services as appropriate;
  • Help patients connect with transportation resources and receive appointment reminders as necessary;
  • Comply with all regulations under HIPAA regulations and the PCMH Program;
  • Maintain appropriate records of outreach activities, participants, and outcomes; and
  • Document all services and contacts in a timely manner in the electronic health record system and other tracking systems

Skills:

  • Thorough knowledge of community resources, including health systems and social services
  • Excellent time management skills and attention to detail to attend to program target goals and to ensure timely documentation
  • At least two years of experience with vulnerable populations, including incarcerated, substance use and/or mental health disorders; knowledge of Philadelphia is a plus
  • Ability to adapt to fast paced medical environments and demonstrate flexibility in operating within different work and community settings
  • Knowledge of medical (especially chronic diseases) and behavioral health conditions
  • Excellent interpersonal, organizational, and oral/written communication skills
  • Ability to represent the agency and facilitate a relationship with the community and other providers
  • Ability to maintain client confidentiality
  • Written and oral fluency in Spanish and English preferred
  • Valid US Driver’s License

Experience:

  • Understanding of how to engage diverse populations ( i.e. race, ethnicity, diagnoses, age, economics)
  • Experience working in a community-based setting for at least 1 to 2 years preferred
  • Familiarity working as a member of an interdisciplinary team
  • Knowledge of some medical terminology preferred
  • Experience driving large vehicles

 Education Requirement:

  • High School Diploma/GED required

Salary:

  • Commensurate with education and experience