Community Health Advocate - New York

Description

Job Description

Company: Oak Street Health

Title: Community Health Advocate (RBE)

Location: Remote / Field-Based - Multiple Locations

Role Description

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.

Core 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 enteractions 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

What We’re Looking For

Degree Requirements and Minimum Experience Required:

• 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

Skill Requirements:

• 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

What does being Oaky look like?

• Radiating positive energy

• Assuming good intentions

• Creating an unmatched patient experience

• Driving clinical excellence

• Taking ownership and delivering results

• Being relentlessly determined

Why Oak Street Health?

Oak Street Health is on a mission to rebuild healthcare as it should be, providing personalized primary care for older adults on Medicare, with the goal of keeping patients healthy and living life to the fullest. Our innovative care model is centered right in our patient communities, and focused on the quality of care over volume of services. We are an organization on the move! With over 200+ locations and an ambitious growth trajectory, Oak Street Health is attracting and cultivating team members who embody Oaky values and passion for our mission.

Oak Street Health 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

Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply. 

Learn more at www.oakstreethealth.com/diversity-equity-and-inclusion-at-oak-street-health