Transitions of Care and Coordination

Job Summary

This position is part of the Ambulatory Care Management/Transitions of Care team and is one of 9 CHW roles on the team. The position will be hybrid with some time in either the 426 Michigan office and/or the Residency clinics at 25 Michigan as well as time at home working with patients. The role covers 4 primary care practices along with secondary coverage for other primary care practices. The CHW is responsible for screening for health-related social barriers, provision of resources and facilitating successful navigation of the health care system and community resources.

Essential Functions

• Participates in community events and activities that promote the awareness of health maintenance and disease prevention.
• Conducts home visits to determine client and family needs. Assists with the development and implementation of care plans to meet identified needs and provides program services. Follows up with clients, families, and community agencies to evaluate effectiveness of services provided and to develop a proactive plan for future needs.
• Assists clients with arranging and keeping medical appointments. Assists clients in accessing community resources such as food, clothing, shelter, and medical insurance. Mentors, empowers and advocates for clients and families to help them increase independence and skills.
• Refers patients with social, emotional, and other challenges to appropriate service agencies for assistance.
• Communicates and collaborates with the clients and their families, program staff, and other professionals involved in the care of clients to coordinate services and to facilitate a supportive relationship between the client and their health care provider(s). Serves as a resource to program staff about situational and cultural factors impacting the client, family, and environment. Teaches clients and families about wellness, disease prevention, and self-management.
• Documents services including assessments, plans, and periodic evaluations of goals, education, and other pertinent program data. Documents trends and changes in the health of the community and provides input into program development and evaluation.
• Coordinates group meetings under the direction of the Program Supervisor. Collects and documents program data and other necessary evaluation data to ensure timelines and accuracy. Discusses trends, challenges, and other issues regarding data collection with the Program Supervisor.

How Corewell Health cares for you

• Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
• On-demand pay program powered by Payactiv
• Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
• Optional identity theft protection, home and auto insurance, pet insurance
• Traditional and Roth retirement options with service contribution and match savings

Qualifications

Required

• High School Diploma or equivalent and successful completion of the paraprofessional CHW Training Program (Completion within 180 days from hire date)

• CRT-Basic Life Support (BLS) - AHA American Heart Association WITHIN 90 DAYS Or
• CRT-Basic Life Support (BLS) - ARC American Red Cross WITHIN 90 DAYS
• LIC-Driver's License - STATE_MI State of Michigan Upon Hire
• CRT-Auto Insurance - UNKNOWN Unknown Upon Hire

Preferred

• Associate's Degree or equivalent

• 3 years of relevant experience Work experience
• Knowledge and use of community resources; social, health and public agencies and services.

About Corewell Health

As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence.

Primary Location

SITE - ICC Downtown - 426 Michigan St - Grand Rapids

Department Name

Care Management - Alternative Care - GR

Employment Type

Full time

Shift

Day (United States of America)

Weekly Scheduled Hours

40

Hours of Work

8:00 a.m. - 4:30 p.m.

Days Worked

Monday - Friday

Weekend Frequency

N/A

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Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.

Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.

You may request assistance in completing the application process by calling 616.486.7447.