POSITION TITLE: Lead Community Health Specialist
REPORTS TO: Director of Community Support and Recovery Services
FLSA Status: Non-Exempt
Date: January 2024
General Definition and Scope of Job
The Lead Community Health Specialist will be an integral member of the Community Care Specialist program and the care team. She or he will work with the Community Support Manager to ensure the smooth operations of the program across all Manet sites. The Lead CHS will work closely with care managers, other care management team members, health care providers, social services and behavioral health providers and community partners. The Lead CHS will serve as a liaison/link/intermediary between the care team and the community to facilitate access to services, reduce barriers, increase cultural competency and actively build individual and community capacity.
Core Responsibilities
- Helps organize CHS onboarding materials and train new staff.
- Provides manager with feedback regarding CHS’s daily responsibilities and progress during training period.
- Serves as mentor and coach to CHSs and provides support on a day-to-day basis.
- Ensures consistency of standards for CHSs.
- Provides general oversight of all sites’ CHS buckets to ensure timely responses to patient cases.
- Presents at internal and external meetings to outline CHS role and services.
- Takes on leadership and new initiatives.
- Assists in ensuring adequate coverage and access to services across all sites in order to meet the needs of patients.
- Coordinates BACO flex program and serves as point of contact on behalf of Manet.
- Conducts patient outreach and engagement activities including face to face, mail, electronic and phone contact.
- Conducts outreach and engagement activities that support patient continuity of care, including re-engaging patients in care if they miss appointments and/or do not follow up on treatment.
- Supports the development and execution of patients’ care plans, including assisting patients in understanding care plans and instructions and tailoring communications to appropriate health literacy levels.
- Promotes patient treatment adherence through assisting patients in making changes to daily routines, identifying barriers and assisting patients with developing strategies to address barriers.
- Provides informal counseling, behavior change support and assistance with goal setting and action planning.
- Assists patients with navigating health care and social service systems including arranging for transportation and scheduling patient appointments.
- Assists care managers in monitoring and evaluating patients’ needs, including for prevention, wellness, medical, specialist, and behavioral health treatment, care transition and social and community service needs.
- Identifies available community-based resources and actively manages appropriate referrals, access, engagement, follow-up and coordination of services.
- Coordinates patients’ access to individual and family support and resources.
- Provides support for chronic disease self-management to patients and their families.
- Coordinates access to the basic determinants of health (e.g., food, clothing, shelter, utilities).
- Collects and reports on data for program evaluation.
- Provides information on patients to care managers, other care team members, and providers.
- Documents in medical record patient information and interventions.
- Other duties as assigned.
Minimum Skills, Experience and Educational Requirements
Education:
- High School diploma or GED required. Associate’s degree preferred in Human Services field.
- 2-3 years related work experience preferred.
- Minimum 2 years of related work experience without a related Associate’s degree
- Excellent verbal and written communication skills.
- Experience with computer systems required, including web based applications and some Microsoft Office applications which may include Outlook, Word, Excel, PowerPoint or Access.
Critical Demands of the Job
- Bi-lingual capacity preferred for outreach to underserved and hard to reach populations, including Chinese, Portuguese and Arabic speakers.
- Manage multiple requests and prioritize appropriately.
- Must be able to consistently demonstrate integrity, compassion and respect, diversity and teamwork, excellence and innovation in work activities and interactions.
- Ability to function in a fast-paced setting with a variety of patients and staff.
- Attention to details and prompt follow-up.
- Includes walking and standing for long periods of time, sitting for short periods of time, hand dexterity, clear hearing and speaking ability. Must be able to lift a minimum of 1/3 of their body weight.
- Excellent organizational and interpersonal skills.
Working Conditions
- Works in well-lighted environment with comfortable surroundings.
- Stressful at times due to competing demands, including attention to multiple patients and staff.
- Will comply with all applicable laws and will cooperate with the Manet Community Health Center compliance program rules and regulations.
Required Availability
May be required to work evenings, holidays or weekends.