Job Description

About Grace At Home

Grace at Home is a provider-led, community-based health and care partner dedicated to improving the health and well-being of those who need care the most, with a deep commitment to high-needs, urban and rural communities. Our local physicians, nurses, and caregivers work together to serve people and the communities they live in, beyond just treating symptoms. We remove barriers by delivering personalized care as close to home as possible, often in-home, because we know a deep understanding of our patient’s race, culture, and environment is critical to delivering improved health outcomes. By empowering patients, providers, and caregivers with the support they need, we strive to make health and care a reality—not a burden—every single day. Join us in creating a better way to care.

About the Job

Reporting to the Community Care Manager, the Community Health Worker is a member of the Grace at Home interdisciplinary care team, providing in-home support to Grace at Home patients and their families as they navigate the often-complex health care systems. This role serves as a vital link between patients, their communities, and care providers. Through addressing individual patients’ unique barriers to care and social determinants of health, the Community Health Worker ensures improved health outcomes and overall quality of care in coordination. They are a patient advocates, ensuring that their voices are heard and their needs are met within the healthcare system. This position is a community-based position that will require you to be in the community and meeting with patients face to face in their homes, at doctor appointments, libraries, or other locations within the community agreed upon by the participant and the CHW.

Responsibilities

• Establish rapport with patients and their families to facilitate open communication and understanding of their health needs during transitions; providing patients with essential information about their health conditions and self-management strategies, as directed by the clinical team.
• Conduct in-home monthly or bimonthly visits with patients based on risk stratification.
• Conduct telehealth video visits with appropriate clinical or social resources to address the patient’s real-time clinical, behavioral, or social needs. Ability to utilize appropriate monitoring equipment for telehealth video visits.
• Collaborate with healthcare providers, social workers, and community organizations to ensure that patients receive comprehensive care. This includes scheduling follow-up appointments, arranging transportation, and coordinating home health services.
• Assist patients in navigating insurance and healthcare policies, accessing community resources such as financial assistance programs, housing support, and healthcare services to help them manage their health effectively.
• Be sensitive to the diverse cultural backgrounds of patients, ensuring that care is respectful and tailored to individual needs.
• Utilize evidence-based assessments and approaches to help patients identify and prioritize their health, address social challenges, and utilize community-based resources.
• Establish and maintain working relationships with primary care providers, interdisciplinary teams, and community-based programs to ensure coordinated care for patients.
• Engage in care coordination efforts to assist patients in identifying barriers to health and well-being and collaborate to address those challenges effectively.
• Accurately document all visits and patient interactions in the electronic medical record (EMR) and team tracking systems.
• Maintain detailed records to ensure continuity of care and assist in monitoring the progress of patients.
• Perform other job-related duties as assigned.

Qualifications

• Education: Associate degree or a combination of education and experience required; B.S or B.A. preferred.
• Experience: 2+ years in the healthcare arena or exposure to health care systems required. Experience as a Community Health Worker or equivalent supporting vulnerable populations required.
• License/Certification: CPR certification is required. CHW certification is a plus.
• Communication: Excellent verbal, written communication, and presentation skills; ability to clearly articulate and present concepts and models in an accessible manner to Grace at Home’s team and patients with the ability to build trust and rapport, in-person and over the phone, with individuals from diverse backgrounds.
• Relationships: Ability to build and effectively manage relationships internally and externally.
• Culture: Good judgment, impeccable ethics, and a strong team player; desire to succeed and grow in a fast-paced, demanding, and entrepreneurial company.
• Unrestricted driver’s license in home state required.
• Ability to work collaboratively with healthcare teams and community organizations to address the complex needs of participants.
• Experience working with electronic medical records (EMR) and care management system.
• Strong knowledge of HIPAA regulations and ability to handle sensitive and confidential information with discretion.

Benefits

Financial Well-being

• Competitive Compensation: We offer competitive salaries to attract and retain the best talent.
• 401(k) with Employer Match: Plan for your future with our 401(k) plan and a generous 4% employer match.

Health and Wellness

• Comprehensive Medical Plan: We proudly offer a comprehensive medical option with an employer contribution.
• Dental & Vision Coverage: Maintain your oral and eye health with our employer-paid dental and vision plans via MetLife.
• Employer-Paid Insurance: Life, Short-Term Disability (STD), and Long-Term Disability (LTD) insurance are provided at no cost to you.
• Generous Paid Time Off: Enjoy ample time off for rest and rejuvenation with generous PTO, holidays, and wellness time.

Additional Perks

• Continuing Medical Education (CME) Allowance for Providers: Stay at the forefront of your field with our CME allowance.
• Commuter Benefits: Save on your commute with our commuter benefits program.
• Mileage Reimbursement: Get reimbursed for work-related travel expenses.

The working environment and physical requirements of the job include:

This position requires in-home, assisted living, and independent-living community-based work. The job requires frequent travel for patient visits in all types of weather conditions. Work may be performed in settings with conditioned air, artificial light, and an open workspace.

Equal Opportunity & Reasonable Accommodation Statement

Grace at Home is an Equal Opportunity Employer committed to creating an inclusive environment for all employees. We provide equal employment opportunities to all individuals regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected characteristic under applicable law.

If you require a reasonable accommodation during the application or employment process, please indicate this in your application or speak with your recruiter during the hiring process.

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