Peer Support to Patients with complex and multiple chronic conditions
Full Time Permanent Position
Monday – Friday, 8:00AM-5PM
Growing Company
Going out in the community to find/connect with patients and act as a liaison to connect them with a Provider to get the care they need
Bilingual in Spanish Required
Background in Social work, Public Health, Community Outreach
RESPONSIBILITIES
Conduct health-related social needs screening and peer support in the field, home, or by phone, on issues related to social support, food insecurity, nutrition and physical health literacy, social isolation, housing safety, homelessness, transportation barriers, job/financial insecurity, among others.
Provide ongoing follow-up, motivational interviewing and goal setting with patients/families.
Support Member in the home by reviewing and updating After Visits Summary (AVS) and Health Action Plans (HAP) to assist patients in achieving goals.
Assist call center by completing field visits to patients for purpose of program enrollment/new patient appointments and reengagement of noncompliant patients.
Work with patients on developing achievable goals to enhance their daily living.
Help patients make healthy and supportive connections in the community
Support patient access to local community-based organizations, self-help groups, and other relevant organizations, ensuring warm handoffs to service providers.
Support patient in improving completion of medical appointments.
Complete timely bedside visits while patient is admitted to the hospital.
Coordinate discharge planning needs with hospital staff, case management and/or other care team members
Document peer support activities, monitor patient progress, update the care team, and maintain thorough notes.
Support the growth and development of the Health Coach initiative across care teams by providing timely feedback and active participation on relevant projects.
REQUIREMENTS
Bachelor's Degree (preferred) or commensurate work experience
Bilingual (Spanish) Required
Experience providing peer support to patients with complex and multiple chronic conditions and challenging social and mental health conditions (e.g. Community Health Worker, Patient Navigator, In-Home Support Specialist, etc.)
Training or experience in community health, social determinants of health, and peer counseling.
Knowledge of community-based healthcare and social services systems and the needs of medically underserved populations, and older adults/seniors
Understanding of mental illness and addiction and ability to engage with clients who struggle with these issues at all levels.
Strong interpersonal and social skills with demonstrated ability to collaborate with a variety of individuals from a wide range of professional and personal backgrounds.
Ability to thrive in a complex and rapidly changing environment.
Ability to build credibility and trust with clients/patients.
Maintains confidentiality and follows HIPAA standards in safeguarding patient information.
Good oral and written communication skills.
Strong organizational skills.
Basic knowledge of Microsoft Office.
Training and experience in using Motivational Interviewing strongly preferred
Knowledge and/or experience within Home support Services (IHSS) is highly desirable
Must have valid driver’s license and auto insurance
Must have reliable transportation
Willing to meet travel requirements
Must be COVID vaccinated or willing to get the vaccine before starting
