Community Health Worker- Home Provider Program (Telecommute) Duties: Assesses client and home environment to identify physical, social, emotional and knowledge barriers to optimal client care. Identified pertinent information and communicates to care team. Facilitates client's health through advocacy, support with understanding and use of benefits, assistance in scheduling appointments, development of a support system, and reinforcement of self management and organizational tools. Supports client well-being by using strong observation and communication skills to coordinate care between physician office, client, caregiver and community resources. Provides ongoing face-to-face or telephonic visits with clients to identify barriers to accessing care, and supporting the plan of care developed by PCP and Care Manager. Contributes to the development of individualized care plan by using evidence-based guidelines and clinical knowledge, for client and provider, by evaluating and conducting home visits, gathering assessment information, and identifying problems, goals and interventions. Assists clients and caregivers in taking an active role in health management and promotion, through coaching, education, navigation and referrals to appropriate care and community based resources. Comprehensive knowledge of community and public resources serving the client population. Thorough understanding of how to access/maintain and actively assists clients to secure resources. Reviews adherence to physician's recommendations, assessing barriers to care, and documenting information for the care team. Develops cross-functional relationships with medical groups by attending appropriate meetings, working on-site, and structuring effective communication mechanisms. Exhibits strong interpersonal, critical thinking and analytical skills through positive communication with clients, caregivers, care team and community agencies. Demonstrates excellent organizational, decision-making and multi-tasking skills as demonstrated by problem solving and successful outcomes. Completes timely and accurate documentation in multiple computer systems to record assessment, observations and corresponding documentation, including care plans, and progress notes. Enhances skills and knowledge by participating in educational offerings and team case conferences and training per department guidelines. Utilizes department desktop procedures, workflows, job aids and training material. Identifies barriers to work processes and brings to the attention of the supervisor/manager. Maintains the client's right to privacy Adheres to all quality, compliance and regulatory standards to achieve desired outcomes. Contributes to team effort by accomplishing related results, as needed. Bilingual English/ Spanish. AA degree, or 2+ years of college in human services field. Proficient in MS Office. Broad understanding of local community resources for seniors and disabled. Understanding of confidential information. Working knowledge of medical terminology and abbreviations. 2+ years of experience in community services, in a healthcare environment; Medicare/Medicaid experience. 2+ year experience with geriatrics and disabled individuals and their families, community-based experience. Work is primarily in the field (based out of home office), must be willing to travel in assigned locality. Bi-monthly office visits to assigned locality. Bachelor's Degree Care Navigators On Demand is an Equal Opportunity Employer and does not discriminate on the basis of race or ethnicity, religion, sex, national origin, age, veteran disability or genetic information or any other reason prohibited by law in employment.