Case Manager-Certified CommunityHealthWorker

JOB DESCRIPTION

POSITION TITLE: Case Manager-Certified Community Health Worker

DEPARTMENT: Operations

FLSA STATUS: Non-Exempt

PAY GRADE: 9

REPORTS TO: Senior Director of Administration

GENERAL DESCRIPTION OF DUTIES

The purpose of this position is to support the Agency’s needs by providing support based on CRT’s Steps to Success model, the Certified Community Health Worker (CHW) is responsible for providing a wide-range of services; including, but not limited to, outreach, engagement, education, coaching, informal counseling, social support, advocacy, care coordination, and basic screening and assessments of any risks associated with social determinants of Health. As a priority, activities will promote, maintain, and improve the health outcomes of customers. Daily monitoring of customer contacts and activities within the Community is a primary responsibility. The Certified CHW conducts assessments of customer needs and coordinates referrals to Community Renewal Team programs and initiatives, Funder services, entitlement programs, as well as, to other Community resources that conduct Case Management services.

SPECIFIC DUTIES AND RESPONSIBILITIES

ESSENTIAL JOB FUNCTIONS

The list of essential functions, as outlined herein, is intended to be representative of the tasks performed within this classification. It is not necessarily descriptive of any one position in the class. The omission of an essential function does not preclude management from assigning duties not listed herein if such functions are a logical assignment to the position.

• Identify/Provide outreach and engagement functions to customers in the Community.
• Identify customers in need of Case Management and/or other Outreach Engagement services; linking them with available services.
• Interview customers on and/or off site as required.
• Complete Universal Screening to determine Program eligibility.
• Assist customers in their Homes, Community, or Clinical setting.
• Establish positive and supportive relationships with the customers.
• Complete an initial interview and assessment of individual needs.
• Assess and evaluate customer needs based on the Outcome Scale Matrix (OSM).
• Develop Individualized Service Plans (ISP) for each customer, and incorporate all special needs.
• Facilitate referrals to Clinics and Community Support services.
• Facilitate communication/coordinate services between providers and customers.
• Coordinate/Monitor services to include comprehensive tracking of customers compliance in relation to ISP goals and objectives.
• Provide support, advocacy, and mediation services to assure customer’s overall needs and referrals are being conveyed.
• Follow-up with both customer and provider regarding ISPs.

• Document all encounters/interactions made with and/or on behalf of the customer; including all activities, ISPs, and outcomes achieved by the customers in a detailed and timely manner.
• Conduct monthly home visits with customers as needed; documenting all visits in the customer’s file.
• Conduct bi-weekly conversations with the customer either by phone or in-person; documenting all conversations in the customer’s file.
• Maintain client records in accordance with documentation requirements and standards.
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