Community Health Worker

CCI Health & Wellness Services Greenbelt, MD
CCI Health and Wellness Services is a group practice, empowering patients to partner with staff for an unparalleled healthcare experience. Through integrated teams in a learning environment, we deliver high quality, affordable, care to every patient during all stages of life.


Under the direction of the HIV Care Team, the Community Health Worker will conduct culturally appropriate care coordination, health education and outreach activities in health center and community-based settings such as patient homes, clinics, and community centers. The Community Health Worker will assist patients to access the variety of social and medical services they need to maintain their health. The Community Health Worker will collaborate with the HIV Care Team and to promote health and wellness and contribute to the goals and objectives of the patients' care plans.

As a member of the health center's integrated care team the Community Health Worker (HIV) will fulfill the following KEY FUNCTIONS AND RESPONSIBILITIES towards the provision of patient centered, coordinated patient care:

* Establish trusting relationships with patients and their families, and provide general support and encouragement

* Provide ongoing follow-up, basic motivational interviewing and goal setting with patients/families

* Conduct intake interviews with patients to assess needs, and make referrals to community agencies and programs as needed

* Follow-up with patients by phone, home visits and visits to other settings where patients can be found

* Assist patients with completing applications and registration forms

* Conduct eligibility determination, enrollment and follow-up with uninsured patients

* Assess needs and help patients set personal goals to improve/maintain compliance with the plan of care

* Assist patients to access transportation resources and provide appointment reminders in special circumstances, transporting patients is strictly prohibited

* Work closely with HIV Care Team to help ensure that patients have comprehensive and coordinated care

* Maintain an updated list of community resources appropriate to needs of patients/families

* Provide consistent communication to the HIV Care Team to evaluate patient/family progress, ensuring that provided information and reports clearly describe progress.

* Act as a patient advocate and liaison between the patient/family and community service agencies (e.g. schools, Department Human Services, Heath Care for Homeless, hospitals, support groups, etc.).

* Record patient care management information in the EMR (training provided) and other software no later than 24 hours after patient contact

* Attend regular staff meetings, trainings and other meetings as requested

* Manage assigned caseload of patients

* Other duties as assigned


* High School Diploma or its equivalent

* Successful completion of a Community Health Worker training program from a college or other education institution

* Comfortable working with individuals who do not speak English using a language line.

* Experience working in a multi-cultural, community-based setting for at least 1 to 2 years preferred

* Knowledge of some medical terminology preferred

* Basic computer skills

* Understanding of the community served

* Experience working with people living with HIV preferred

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