Community Health Worker, Integra

Integra Community Care Network; Warwick (RI); On-site; USD 42,000 - 56,000; Full time

Job summary

Integra Community Care Network is seeking a Community Health Worker to join the care team in Rhode Island. You will support patients with complex health and social needs through home-based, community-focused interventions and sustained care coordination.

The role emphasizes SDOH screening, resource navigation, and collaboration with primary care teams to improve health outcomes and health literacy in diverse communities.

Qualifications

• High School diploma required with ability to carry out responsibilities.
• Certification in Community Health Work or in progress, must obtain within 12 months.
• Associate's or Bachelor's in Social Work, Community/Public Health or related field a plus.
• Experience with primary care or other healthcare settings.
• Experience with patient health management, navigation, care coordination and coaching preferred.
• Ability to travel within the state and reliable transportation.
• Valid driver's license, insurance, and transportation required.
• Ability to speak a second language, Spanish preferred.

Responsibilities

• Assist Integra In-Home patients in securing community resources identified through SDOH screening and in-home assessment.
• Act as liaison between patient and community resources.
• Perform SDOH screening and assessment of patient needs to remain in the community.
• Assist with management of chronic condition disease management programs for BCBS members.
• Provide navigation, support, care coordination and ongoing case management to meet patient needs.
• Visit patients in homes and communities, delivering culturally sensitive health information to improve health literacy.
• Facilitate patient decision-making and self-management to engage in health goals.
• Track patient activities, monitor and document progress.
• Collaborate with primary care team and participate in multidisciplinary patient-centered team meetings.
• Engage with community agencies to identify resources and improve population health.

Job description

Job Summary

The Community Health Worker is a member of the community health team; an interdisciplinary team comprised of Community Health Workers, In- Home team nurse care managers, schedulers, resource specialists, health navigators and nurse practitioners. Works closely with the core team members to support patients who are dealing with complex medical, behavioral health and/or substance issues as well as social determinants of health, and require a more intensive home and community-based intervention.

Duties & Responsibilities

• Used to assist the Integra In-Home patients in securing community resources identified through the SDOH screening and in-home assessment.
• Acting as a liaison between the patient and the community resource.
• Would be responsible for the SDOH screening and assessment of the patients needs to remain in the community.
• Assist with the management of the newly implemented chronic condition disease management programs for BCBS members.
• The Community Health Worker plays a critical role in assessing patient needs, offering community resources and referrals, providing navigation, support, care coordination, and ongoing case management to meet those needs.
• Visits patients in their homes and in the communities in which they live, providing culturally sensitive approaches to health information to improve health literacy.
• The Community Health Worker facilitates the patient’s decision-making and self-management to help patients engage in their overall health and achieve their health goals.
• This individual will be responsible for tracking patient related activities, monitoring and documenting progress.
• Works collaboratively with the primary care team to promote patient-centered care and actively participates in multidisciplinary patient-centered team meetings.
• The Community Health Worker has frequent contact with many community agencies on behalf of the patients served, networking and collaborating on resource identification to improve the overall health of the population.

Requirements

• High School diploma required with a combination of training and skills to effectively carry out responsibilities and assignments (such as previous experience working with patients in a community-based setting).
• Must have Certification in Community Health Work or is working toward certification, must obtain certification within 12 months.
• Associates or Bachelor’s degree in Social Work, Community/Public Health or related health sciences field a plus.
• Experience working with primary care providers or in other healthcare settings.
• Experience working with patients regarding managing their health, navigating systems, providing care coordination and health coaching is preferred.
• The ability to travel to various locations in the state and reliable transportation is required.
• Must possess a valid, current state issued driver’s license, have reliable transportation and proof of current auto insurance required.
• Ability to speak a second language, Spanish preferred.

About Us

Care New England Health System (CNE) and its member institutions, Butler Hospital, Women & Infants Hospital, Kent Hospital, VNA of Care New England, Integra, The Providence Center, and Care New England Medical Group, is a trusted, integrated health care organization that fuels the latest advances in medical research, attracts the nation’s top specialty-trained doctors, hones renowned services and innovative programs, and engages in the important discussions people need to have about their health and end-of-life wishes. Care New England is helping to transform the future of health care, providing a leading voice in the ongoing effort to ensure the health of the individuals and communities we serve.

EEO Statements

Americans with Disability Act Statement: External and internal applicants, as well as position incumbents who become disabled must be able to perform the essential job-specific functions either unaided or with the assistance of a reasonable accommodation, to be determined by the organization on a case-by‑case basis.

EEOC Statement: Care New England is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status

Ethics Statement: Employee conducts himself/herself consistent with the ethical standards of the organization including, but not limited to hospital policy, mission, vision, and values.