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Community Health Worker, Health Home

CAMBA's Health Home program is an innovative new model of care management focused on improving the health outcomes for individuals with severe mental illness & other complex chronic illnesses through coordinated networks of medical, psychiatric, behavioral health, social service & housing providers.  The Health Home program is partnering through a contract with NY Presbyterian Hospital to have 2 Community Health Workers (CHWs) perform health- related educational services in connection with the hospital's Adult CHW Initiative.  The CHWs will receive referrals from the hospital to consent and enroll individuals into the program and then work with them for approximately 6 months.  The CHWs will escort them to appointments; make referrals to appropriate services; provide health education; help to develop educational workshops and health fairs; and perform other duties as assigned. 


Essential Duties and Responsibilities:  The person filling this position is expected, under close supervision, to: (1) work as part of the health care team to deliver New York-Presbyterian-based and Health Homes-based health education utilizing agreed upon materials and protocols; and (2) assist eligible clients in attaining their goals by identifying and locating community resources for clients and by making referrals to appropriate services both within and outside CAMBA; including the following:    ​

  • Participates in outreach, planning and execution of special events, including workshops, health fairs, jointly agreed upon community events, and the annual Community Health events such as the family graduation.
  • Attends all ACN Community Health Worker staff meetings and events.
  • Attends local project case management meetings and may attend practice based interdisciplinary team meetings.
  • Attends patient medical visits and accompanies patients at social service visits, as needed.
  • Collaborates with other NYP team members such as patient navigators, community navigators, social workers, care managers, and care coordinators to improve patient outcomes
  • Visits the homes of program participants to provide in person education and support, along with other activities, including home environmental assessment, as determined by specific program.
  • Conduct telephone and online directory searches to secure up-to-date contact information for eligible individuals.
  • Educate eligible individuals about the health benefits of the program (i.e., email and/or mail program & enrollment information, make phone calls to individuals, their Health Home providers and family members).
  • Schedule intake appointments between the eligible individuals and the care management team as needed.
  • Assist eligible individuals with completing all CAMBA and Health Home enrollment and consent forms.
  • Conduct initial needs assessments of clients and clients' families.
  • Work with clients to break through barriers to their goals and to assist them in advocating for themselves and in moving toward self-sufficiency.
  • Assist clients in completing applications for benefits and entitlements (e.g. Medicaid, etc), and process applications on clients' behalf.
  • Monitor clients' progress towards their service goals, and document all interactions with clients via progress notes.
  • Create and maintain client files and make copies of all client documents.
  • Enter client data (i.e. client services, progress, outcomes, contact information, etc.) into automated database.
  • Provide all required information for weekly/monthly/quarterly/annual reports (i.e. client services reports, documentation ticker/ tracking reports, client contact reports, vehicle incident reports).

Minimum Education/Experience Required:

  • High school diploma or G.E.D. preferred and/OR
  • At least two years of experience as a Community Health Worker or  working within the Health Care field providing services such as patient outreach, recruitment and enrollment; patient education, and/or care management.

Other Requirements:

  • Knowledge about, understanding of, and ability to work closely with, persons with chronic illness and related issues.
  • Knowledge of community resources and sensitivity toward persons with chronic illnesses.
  • Follow all HIPAA privacy rules as they relate to personal health information and documentation.
  • Some evenings and/or weekends may be required.
  • Ability to utilize public transportation to navigate the five boroughs of New York City.
  • Bi-lingual English/Spanish and/or English/Creole speakers required.
  • Ability to utilize mobile technology as a tablet to document while performing field work.

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