Job Description

POSITION SUMMARY :

The Community Wellness Advocate (CWA) assists at-risk members maintain stable health and wellness along a continuum through integrating and connecting acute care, primary care, home-and community-based services and other services.  The CWA actively outreaches to the member both telephonically and in-person to engage the member in their care and self-management, facilitate access to services, educate and coach, and identify unmet needs in a culturally and linguistically appropriate manner.  The CWA works collaboratively with the Interdisciplinary Care Team (ICT) to increase member knowledge, motivation, and compliance with their Individual Plan of Care (IPC) based on the member’s identified needs.  The CWA provides advocacy and helps the member and their caregivers navigate and access services and resources, both internal and external, that support the member’s well- being and choices. The CWA influences engagement using Motivational Interviewing skills and conducts evidence-based programs/education based on the member’s IPC, monitors their progress, and problem solves to accelerate and enhance concrete supports.   Assisting in transitions of care with the Primary Care Team (PCT) to ensure the member has required supports upon return to the community  is another CWA role in maintaining and improving the member’s health status and reducing risks.

Position: Community Wellness Advocate        

Department: Pop-Health Care Management

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

Key Functions/Responsibilities

• Supports the Lead Care Manager in delivering integrated Care Management across the continuum of care
• Coordinates community-based access and delivery that provides for needs such as education, health care, nutrition, financial, legal, transportation, access to appointments, and housing referrals
• Assists in implementing integrated person-centered care plans that address barriers to care
• Directly manages members in the moderate and low-risk groups including self-care education and coordination of services. May support high-risk Care Management, transitional care and, Maternal and Child Health specialists
• Initiates and establishes trusting relationships with member’s and their caregivers/families while providing support, encouragement, and education
• Initiates face-to-face contact with identified members to establish authentic meaningful working relationships, and explain benefits and services.
• Conducts screening in-person with the members, recommends goals for the IPC, participates in Primary Care Team meetings and communication, conducts follow up visits and phone calls within identified timeframes
• Provides basic motivational interviewing and goal setting with Members and their families/caregivers and provides guides to achieve those goals
• Teaches key educational messages/programs that are evidence-based and that are part of the IPC using culturally, linguistically and educationally appropriate strategies in a variety of settings and documents activities in the care management system
• Demonstrates ability to work as part of an inter-disciplinary team
• Completes documentation of all contacts, assessments and other information in the medical management system in a timely manner and in keeping with contractual requirement, internal policy, and accreditation standards
• Works closely with Care Managers and external Care Team members to ensure care is coordinated, member is connected with resources, and there is adequate follow up
• Assists members with organizing their records, making follow up appointments, attending appointments and filling prescriptions as needed
• Helps member fill out applications as needed
• Collaborates with the Care Managers and the Transitions of Care Team to assist members with transitions to other care settings and back to the community including visits to facilities as well as their residence
• Prepares reports and documents as needed or requested
• Participates in required training
• Participates in community outreach activities
• Maintains HIPAA standards and confidentiality of protected health information
• Adhere to Company and Department Policies and Procedures as well as State Contractual Requirements
• Other duties as assigned

Supervision Exercised

• None

Supervision Received

• Regularly scheduled meetings with Manager of Care Management

JOB REQUIREMENTS

Qualifications

Education Required:

• BSW, Associate’s degree in health care or a related area or equivalent relevant work experience
• Completion of Community Health Worker training program/certification program or equivalent work experience

Education Preferred:

Experience Required:

• One year  experience as a Community Health Worker or Community/Social  Advocate

Experience Preferred/Desirable:

• Prior work with Medicaid population preferred
• Experience with care coordination/care management
• Experience in healthcare database/medical management system
• Prior customer service experience
• Training in motivational interviewing techniques
• Knowledge and experience in evidence-based prevention programs
• Bilingual
• Successful completion of Community Health Worker formal training/certification program or equivalent

Required Licensure, Certification or Conditions of Employment:

• Pre-employment background check

Competencies, Skills, and Attributes:

• Basic knowledge of the health care system
• Motivational interviewing skills
• Interest and experience in community health and outreach
• Ability to multi-task
• Ability to work independently as well as part of a team
• Knowledge of community based resources and how to build linkages with them
• Demonstrated oral and written communication skills
• Understanding of how language, culture and socioeconomic circumstances affect health
• Desire to work with diverse, multi-cultural, multi-lingual populations
• Intermediate skill level with Microsoft Office products – Outlook, Word, Excel
• Strong data entry and tracking skills

Working Conditions and Physical Effort

• Fast paced environment
• No or very limited exposure to physical risk.
• No or very limited physical effort required
• Regular and reliable attendance is an essential function of the position
• Travel within the plan geographic area required
• Work will be performed in the field as well as some home/corporate office work.

Equal Opportunity Employer/Disabled/Veterans

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