Geisinger
Community Health Worker Certified-3
About this role
Location: Work from home (Pennsylvania)Shift: Days (United States of America)Scheduled Weekly Hours: 40Worker Type: RegularExemption Status: NoJob Summary: The Certified Community Health Worker (CCHW) within the Social Needs Resource Hub (SNRH) provides patient-centered outreach, primarily through telephonic engagement, to individuals with identified social needs. Working within a team-based model, the CCHW collaborates with healthcare teams, community-based organizations (CBOs), and hub colleagues to assess needs and coordinate appropriate support. The CCHW utilizes motivational interviewing and problem-solving techniques to educate patients and connect them to community resources that address social determinants of health, including transportation, food insecurity, housing, financial strain, and utilities. This role includes facilitating referrals and partnering with CBOs through the Neighborly platform to ensure timely and effective linkage to services. The CCHW conducts follow-up outreach to confirm successful connections and address barriers, supporting a shared team workflow and accountability model. Accurate and timely documentation within Geisinger’s electronic medical record (EMR) is required to capture outreach efforts, referrals, and outcomes, supporting reporting, quality improvement, and program evaluation.Job Duties:
- Orientsandassesses newCommunityHealthWorkers.
- Providesregular assessmentofthelevelofproficiencydemonstratedbystaffduring theorientationperiodinordertosupport decisions to move staff along in training or refocus until proficiency is met.
- Assistsintheidentificationandoutreachofmedicallycomplex patients.
- Collaborateswiththemultidisciplinaryteaminthedevelopmentandimplementationofthecareplan.
- Engagespatients bywayofphonecall, homevisit,hospital visit,andaccompanyingpatientstoProvidersappointmentsasneeded.
- Completesvitalsigns.
- Identifiesgapsincareandconnectsmembers withresources.
- Facilitatestelemedicinevisits withmembersandproviders.
- Performsdiseasespecificeducation.
- ConductsMedicationReviewtoensuremedicationadherence.
- Conductssafetyevaluationsinpatientshome.
- Facilitatesadherencetotreatmentplanbyearlyidentificationandresolutionofgapsincare.
- Communicatesallconcerns toclinicalteamandmanager asnecessary,seeking supportandguidance proactively.
- Participatesinmultidisciplinaryteamconferenceinordertomaximizethetreatmentplan.
- ProvidesreinforcementofthetreatmentplanunderthedirectionoftheCaseManagerandLicensedSocial Workerand is available for consultation and case review as needed. Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position. Position Details: Education: High School Diploma or Equivalent (GED)- (Required)Experience: Minimum of 1 year-Related work experience (Required)Certification(s) and License(s): Certified Community Health Worker (CCHW)