Community Health Worker at Aledade, Inc.

As a Community Health Worker, you will work closely with the physician organization, medical providers, primary care teams, and social services agencies to provide short-term care coordination related to Social Determinants of Health (SDOH) needs. Coordination to include linkage to community resources and support programs, assisting patients to improve their health and general well-being through education and provision of appropriate services. Primary Duties: • Conducts outreach to targeted patient population to identify community resource needs • Conducts SDOH screenings on patients • Assists patients in identifying socio-economic issues that affect their overall health and in developing self-management plans and goals • Documents all patient encounters; completes and submits monthly reports; maintains comprehensive electronic patient files. Documents activities, treatment plans, and outcomes achieved by patients in an effective manner. • Facilitates communication and coordinates services between providers and the patients, and tracks patient compliance with the care plan objectives • Provide appropriate billing code for services provided • Creates and maintains a comprehensive community resource database relevant to clinics’ patient populations • Participates in care team meetings and contributes to the patient plan of care Minimum Qualifications: • High school diploma or GED • CHW certification or willingness to obtain upon hire • 1 year experience relevant to position and responsibilities • Resident of Michigan or bordering state • Strong interpersonal and community skills and ability to work effectively with a diverse community • Knowledge of community resources and agencies, for example- knowledge of transportation and other barriers to care • Working knowledge of multi-system outreach programs related to health care delivery, clinical education, and health-related services • Ability to plan, implement, and evaluate individual patient care plans • Ability to communicate medical information to patients over the phone • Skill in use of personal computer and related software applications, including email and excel • Creative and analytical thinking Preferred Qualifcations: • Knowledge of the PCMH and PCMH-Neighbor (PCMH-N) models of care • Experience with EHRs, disease registries, or other medical software • Billing and coding experience Physical Requirements: • Prolonged computer work Who We Are: Aledade, a public benefit corporation, exists to empower the most transformational part of our health care landscape - independent primary care. We were founded in 2014, and since then, we've become the largest network of independent primary care in the country - helping practices, health centers and clinics deliver better care to their patients and thrive in value-based care. Additionally, by creating value-based contracts across a wide variety of health plans, we aim to flip the script on the traditional fee-for-service model. Our work strengthens continuity of care, aligns incentives and ensures primary care physicians are paid for what they do best - keeping patients healthy. If you want to help create a health care system that is good for patients, good for practices and good for society - and if you're eager to join a collaborative, inclusive and remote-first culture - you've come to the right place. What Does This Mean for You? At Aledade, you will be part of a creative culture that is driven by a passion for tackling complex issues with respect, open-mindedness and a desire to learn. You will collaborate with team members who bring a wide range of experiences, interests, backgrounds, beliefs and achievements to their work - and who are all united by a shared passion for public health and a commitment to the Aledade mission. In addition to time off to support work-life balance and enjoyment, we offer the following comprehensive benefits package designed for the overall well-being of our team members: Flexible work schedules and the ability to work remotely are available for many roles Health, dental and vision insurance paid up to 80% for employees, dependents and domestic partners Robust time-off plan (21 days of PTO in your first year) Two paid volunteer days and 11 paid holidays 12 weeks paid parental leave for all new parents Six weeks paid sabbatical after six years of service Educational Assistant Program and Clinical Employee Reimbursement Program 401(k) with up to 4% match Stock options And much more! At Aledade, we don’t just accept differences, we celebrate them! We strive to attract, develop and retain highly qualified individuals representing the diverse communities where we live and work. Aledade is committed to creating a diverse environment and is proud to be an equal opportunity employer. Employment policies and decisions at Aledade are based on merit, qualifications, performance and business needs. All qualified candidates will receive consideration for employment without regard to age, race, color, national origin, gender (including pregnancy, childbirth or medical conditions related to pregnancy or childbirth), gender identity or expression, religion, physical or mental disability, medical condition, legally protected genetic information, marital status, veteran status, or sexual orientation. Privacy Policy: By applying for this job, you agree to Aledade's Applicant Privacy Policy available at  [Upgrade to PRO to see link]