Targeted Care Navigation, Community Health Worker

Targeted Care Navigation Community Health Workers promote wellness by helping members adopt healthy behaviors via implementing personalized care and health plans, advocating for members who may have limited access to health resources, and providing patient self-management support with a focus on empowering the member to build capacity for self-care. They will assess and communicate with members in their homes, as well as by electronic means. They will be a part of an integral team including a Local Nurse Care Manager and an Included Health Virtual PCP.

• Partner with clinical and health plan teams to engage, advocate, educate, navigate, and coordinate with and on behalf of individuals who have been identified as having social needs that impact their health
• Visit patients and members in their home or community settings while also partnering with care management and care teams (e.g., clinics, emergency departments, homecare, health plan, etc.)
• Establish trusting relationships with members and their families to help them become more engaged in their health
• Help patients identify their potential; work to increase individual empowerment and create community connections
• Facilitate  timely enrollment and/or referral into applicable health and community resources
• Assist the patient in navigating to referrals and health-related care settings
• Work closely with care managers and clinical teams to ensure patients have comprehensive and coordinated care
• Support community partnerships
• Maintaining relationships with key stakeholders in the community by serving as an advocate to improve health and social outcomes

• Associate degree
• BLS certification
• Two (2) years healthcare or social services experience in an acute, post-acute, or ambulatory care setting
• Community Health Worker certification as required by the state of Texas.
• Must reside in Houston, Dallas, San Antonio metropolitan area.
• Current driver’s license, reliable transportation, car insurance, and an acceptable driving record with willingness to travel within 50 miles to meet in person with patients in their homes or other medical facilities including hospitals, and local physician offices.
• Able to work independently with strong internal drive, yet able to actively communicate challenges and/or concerns to leadership.
• Excellent interpersonal and facilitation skills
• Excellent time-management skills and an ability to adapt to changing needs/priorities 
• Be highly empathetic with the ability to understand cultural and socioeconomic issues affecting patients and excellent at building rapport with patients and families from diverse backgrounds.
• Basic computer skills
• Demonstrated communication skills (e.g., listening, speaking, writing)
• Willingness to be present on-site in clinical and community spaces
• Experience with various populations, including those with limited financial resources, limited education background and communication barriers.

• MA Certificate or LPN license
• Comfortable with technology and experience working remotely or with innovative care teams
• Experience working with patients in their homes
• Bilingual: Spanish and English
• Ability to have flexible schedule, position may require weekend work

• Driving to member’s homes up to 5 days per week over wide geographical area
• Prompt and regular attendance at assigned work location.
• Ability to remain seated in a stationary position for prolonged periods.
• Requires eye-hand coordination and manual dexterity sufficient to operate keyboard, computer and other office-related equipment.
• No heavy lifting is expected, though occasional exertion of about 20 lbs. of force (e.g., lifting a computer / laptop) may be required.
• Ability to interact with leadership, employees, and members in an appropriate manner.