Job Summary and Essential Function Community Health Workers are natural helpers who build trust with patients and help patients connect with health and social service support, get the care they need, and reach their health goals. They screen diverse populations for social determinants of health needs including food insecurity, behavioral health needs, housing, healthy lifestyles, etc. and assist patients in setting short term goals to help improve their healthcare outcomes, access to care, and empower patients to make sustainable change. This role requires strong communication skills, cultural sensitivity, and a genuine passion for improving health outcomes for patients and communities.Job Responsibilities along with a percentage of time performing duties
60% - Direct in-person and telephonic patient outreach
30% - Documentation
10% - Meetings, program development
Job Function: 01.Work in collaboration with a multidisciplinary team of clinicians as part of the Care Coordination program to provide high quality, outcome-based, patient-centered care for patients to achieve safe transitions of care, improved patient experience, better health outcomes, reduced avoidable cost and utilization, and increased preventative care. Assist high-risk patients address social barriers to care, ensure sustainable connections to health care services, providers, and social supports, and engagement in their plan of care and health outcomes.Job Function: 02.Participate in the AHS CHW training program and onboarding curriculum. Follow departmental policies, procedures, processes, and professional and care standards according to department and organizational guidelines. Regularly attend and actively participate in assigned intradisciplinary and interdisciplinary meetings, team meetings, supervisory sessions, and in-service training.Job Function 03.Engage in proactive community outreach efforts to identify individuals who may benefit from health services and programs. Ensure timely response to referrals from various sources within the health system and adhere to evidence-based care model and maintain documentation and performance metrics according to departmental processes and standards. Maintain a focus on empowering and motivating patients toward self-efficacy, making patient-centered changes in behavior and lifestyle, and long-term sustainable connections and support solutions to achieve their best health.Job Function 04.Meet patients in a medical office, hospital, home, or community setting to get to know the patient as a person, conduct a guided interview, complete a full SDOH screening, and review patient’s health needs and concerns. Partner with the patient to set patient-driven goals for their health and the steps to achieve those goals during your work together. Maintain a focus on building rapport, motivational interviewing, effective listening, cultural sensitivity, and setting goals and expectations. Job Function: 05.Make weekly follow-up calls and home visits to patients to help motivate patients to achieve their health goals. Connect patients with community resources to help with social issues like homelessness, substance abuse and hunger. Assist patients with enrollment in medical, social, and financial programs and benefits for which they are eligible, such as insurance and food stamps. Promote education on preventative healthcare measures, disease management, and healthy lifestyle choices in alignment with patient goals. Assist patients with navigating the healthcare system and accessing medical services including helping them to organize their medical records, schedule follow-up appointments, and access prescriptions.Job Function: 06.Maintain a current knowledge base of community agencies and key contacts and assist with patient advocacy, navigation, and engagement with sustainable medical, social, insurance and benefit systems. Work within Social Services team to maintain an updated directory of community resources. Collaborate with healthcare professionals, social service agencies, and community organizations to ensure patients make sustainable connections with the most appropriate provider.Job Function: 07.Ensure ongoing collaboration and communication with the larger interdisciplinary Care Coordination team, AHS/ACO practices, providers, and care team members to comprehensively address evolving psychosocial needs, medical needs, and plan of care. Maintain accurate and up-to-date documentation of all interactions, services provided, and outcomes achieved. Document each patient encounter in detail and prepare reports and documents as needed or requested. Provide patient-specific and caseload updates to supervising social worker and/or manager on a regular basis. Job Function: 08.Other tasks as required by manager, director, or leadership.Education and/or Experience
High School diploma or GED required; higher educational degree a plus
Long-time resident of or familiarity with a community in the role’s service area and good knowledge of the communities’ challenges and resources.
Prior experience as an outreach worker or customer-service experience a plus.
Knowledge of community resources and social service, financial, insurance, and advocacy systems a plus.
Bilingual in Spanish is a plus.
Licenses, Certifications and/or Registrations
Valid NJ Driver’s License a must
NJ CHW Certificate a plus
ABOUT USAt Atlantic Health System, our promise to our communities is; Anyone who enters one of our facilities, will receive the highest quality care delivered at the right time, at the right place, and at the right cost. This commitment is also echoed in the respect, development and opportunities we give to our more than 20,000 team members. Headquartered in Morristown, New Jersey, we are one of the leading non-profit health care systems in the nation. Our facilities and sites of care include:
Morristown Medical Center, Morristown, NJ
Overlook Medical Center, Summit, NJ
Newton Medical Center, Newton, NJ
Chilton Medical Center, Pompton Plains, NJ
Hackettstown Medical Center, Hackettstown, NJ
Goryeb Children's Hospital, Morristown, NJ
CentraState Healthcare System, Freehold, NJ
Atlantic Home Care and Hospice
Atlantic Mobile Health
Atlantic Rehabilitation
We also have more than 900 community-based healthcare providers affiliated through Atlantic Medical Group. Atlantic Accountable Care Organization is one of the largest ACOs in the nation, and we are a member of AllSpire Health Partners.We have received awards and recognition for the services we have provided to our patients, team members and communities. Below are just a few of our accolades:
100 Best Companies to Work For ® and FORTUNE® magazine for 15 years
Best Places to Work in Healthcare - Modern Healthcare
150 Top Places to work in Healthcare - Becker's Healthcare
100 Accountable Care Organizations to Know - Becker's Hospital Review
Best Employers for Workers over 50 - AARP
Gold-Level "Well Workplace": Wellness Council of America (WELCOA)
One of the 100 Best Workplaces for “Millennials” Great Place to Work® and FORTUNE® magazine
One of the 20 Best Workplaces in Health Care: Great Place to Work® and FORTUNE® magazine
Official Health Care Partner of the New York Jets
NJ Sustainable Business
Named one of America's 50 Best Hospitals by Healthgrades, a World’s Best Hospital by Newsweek and recognized as a Best Regional Hospital in the NY Metro area by U.S. News & World Report.Our Atlantic Neuroscience Institute is the region’s leader in neuroscience care. A hub for the New Jersey Stroke Network, we offer a broad range of advanced neurological, neurosurgical and neurodiagnostic services. We are also certified as a Level IV Epilepsy Center and home to the Gerald J. Glasser Brain Tumor Center, where more brain tumor surgeries are performed than anywhere else in New Jersey. Our CyberKnife® program is the largest and most experienced in the state. We also have a satellite emergency department in Union, NJ, which treats about 40,000 emergency cases each year. Committed to providing exceptional care, Overlook Medical Center has achieved the prestigious Magnet® recognition. This designation from the American Nurses Credentialing Center is the highest national honor for nursing excellence. What’s more, Overlook Medical Center has advanced certification from The Joint Commission for perinatal care and is designated an Advanced Comprehensive Stroke Center. Additional Joint Commission-certified services include behavioral health care, spine surgery, wound care, and primary care medical home (PCMH). EEO STATEMENTAtlantic Health System, Inc. is an equal employment opportunity employer and federal contractor or subcontractor and therefore abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment, on the basis of race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, citizenship status, disability, age, genetics, or veteran status.
