Community Health Advocate - New Jersey

About the position

Community Health Advocates (CHAs) work one-on-one with high-risk patients to get to know them as people and help them do the things that they think will improve their health such as offering a listening ear, connecting them to resources like food delivery, navigating the health system, or working out with them at the YMCA. This is an autonomous position which requires a consistent drive for excellence, ability to make appropriate and timely decisions, listen with empathy, and use effective problem-solving skills. CHAs are responsible for thorough and accurate documentation and working collaboratively within a multidisciplinary care team.

Responsibilities

• Manage a caseload of patients and achieve established benchmarks for patient care
• Meet patients in their homes, at the hospitals or primary care clinic and conduct open-ended needs assessment to understand broadly what patients' goals are for their health
• Use motivational interviewing to help patients create person-centered action plans for reaching their health goals
• Use of critical thinking to create goals for patient success based on both clinical and patient identified goals
• Provide a wide variety of support (including emotional support, referral to community based resources, social services, clinical services, etc.) based on CHA discretion and available resources
• Make weekly contact (follow-up calls and/or home visits) to patients
• Coordinate and communicate with clinical care teams to provide relevant information about patient’s goals, clinical emergencies, and patients concerns, and to obtain medical information needed to inform CHA work
• Co-facilitate a weekly support group for patients, where applicable
• Work with other CHAs and staff to create a directory of community resources (e.g. food banks, housing assistance programs, childcare resources, etc.)
• Attend interdisciplinary meetings with other medical professionals to align on readmission prevention planning
• Expertise in navigating Health Plan benefits and resourcing
• Accompaniment to specialist and provider visits
• Establishing and maintaining positive relationships with hospitals, PCPs, specialists and support staff to ensure seamless care coordination
• Patient advocacy and support while navigating Social Determinants of Health
• Efficient, quality and thorough documentation of patients interactions including actions and goals of care to ensure effective communication among healthcare team members
• Navigate patient enrollment within transitional program and manage referrals from other team members
• Form relationships with and build an inventory of local community organizations
• Other duties, as assigned

Requirements

• High School Diploma required
• Long-time resident of assigned location and good knowledge of the resources of these communities
• Comfortable with home visits and outreach
• Prior experience as an outreach worker a plus

Nice-to-haves

• Ability to exercise good judgment with patients, clinical care teams, others involved in the delivery of interventions
• Ability to effectively manage time and tasks, prioritize, and stay organized
• Excellent oral and written communication skills
• Exceptional active listening skills
• Proficient in MS Word and computer data entry
• US work authorization
• Someone who embodies being Oaky

Benefits

• Mission-focused career impacting change and measurably improving health outcomes for medicare patients
• Paid vacation, sick time, and investment/retirement 401K match options
• Health insurance, vision, and dental benefits
• Opportunities for leadership development and continuing education stipends
• New centers and flexible work environments
• Opportunities for high levels of responsibility and rapid advancement