Community Health Navigator: Complex Care Outreach

Geisinger; Pennsylvania; On-site; USD 38,000 - 52,000; Full time

Benefits offered by this job

Full benefits starting day one

Tuition reimbursement up to $5,000 per

Generous PTO

Wellness program MyHealth Rewards

Family-friendly support and leave

Employee Assistance Program (EAP)

Job summary

Geisinger seeks a Community Health Worker to provide outreach to patients with complex medical and social needs, acting as a resource to navigate the health care system. You will orient new staff, assess proficiency during orientation, identify complex patients, and collaborate with the care team to implement plans.

The role involves home visits, telemedicine facilitation, patient education, and ensuring adherence to treatment plans.

Responsibilities

• Orients and assesses new Community Health Workers.
• Provides regular assessment of the level of proficiency demonstrated by staff during the orientation period to support decisions to move staff along in training or refocus until proficiency is met.
• Assists in the identification and outreach of medically complex patients.
• Collaborates with the multidisciplinary team in the development and implementation of the care plan.
• Engages patients by way of phone call, home visit, hospital visit, and accompanying patients to Providers appointments as needed.
• Completes vital signs.
• Identifies gaps in care and connects members with resources.
• Facilitates telemedicine visits with members and providers.
• Performs disease specific education.
• Conducts Medication Review to ensure medication adherence.
• Conducts safety evaluations in patients home.
• Facilitates adherence to treatment plan by early identification and resolution of gaps in care.
• Communicates all concerns to clinical team and manager as necessary, seeking support and guidance proactively.
• Participate in multidisciplinary team conference to maximize the treatment plan.
• Provides reinforcement of the treatment plan under the direction of the Case Manager and Licensed Social Worker and is available for consultation and case review as needed.

Job description

Geisinger seeks a Community Health Worker to provide outreach to patients with complex medical and social needs, acting as a resource to navigate the health care system. You will orient new staff, assess proficiency during orientation, identify complex patients, and collaborate with the care team to implement plans.

The role involves home visits, telemedicine facilitation, patient education, and ensuring adherence to treatment plans.