Description
Title: Community Health Worker
Location: Various
Company Description
The mission of Oak Street Health is to rebuild healthcare as it should be.
We are a rapidly growing, innovative company of community-based healthcare centers delivering higher quality health and wellness care that improves outcomes, manages medical costs and provides an unmatched experience for adults on Medicare.
The Oak Street model integrates outstanding clinical expertise, technology, and teamwork to deliver improved care quality and cost savings. These cost savings are then reinvested into care in our communities, creating a virtuous cycle of improving community health.
We are a national organization serving over 100,000 patients and we are growing rapidly . We are a diverse team of care providers, service team members, technologists, community outreach experts, business professionals, and more -- all dedicated to our Oaky Values and motivated by our mission. We're looking forward to getting to know you!
Role Description
Oak Street Health takes a team-based approach to providing outstanding patient care. As a part of the care management team, this role will provide care to an underserved segment of the community. Our Care Teams, consisting of a Provider, Nurse, MA and Medical Social Worker, build individual relationships across a panel of 500-800 patients. The Care Team is responsible for delivering excellent, high-touch, primary care, and coordinating the care of our patients throughout the healthcare delivery system. We have support team members that assist with specific tasks and/or cases, such as Behavioral Health Specialist and Care Coordinators.
Community Health Workers are an important part of our Care Teams. Building trust and promoting encouragement are two key objectives. High levels of flexibility, attention to detail, and problem solving are required to be successful. You will be expected to build: relationships with Oak Street Health patients, carry a caseload, manage care plans, perform proactive phone and in-person outreach and assessments to our members based on their care needs, lead and support Care Team decision making, participate in weekly care team meetings, and coordinate clinical and complementary services needed to provide a high quality health care experience from Oak Street Health.
Responsibilities

• Manage low risk referrals defined by care management program (Medical Social Work) and collaborate with social worker on action plans
• Form relationships with patients and their caregivers to support prevention focused care and ED/ hospital diversion, and focusing interventions on reduction of avoidable hospital admissions
• Meet with patients in patient centered and patient preferred location (e.g., center, facility, home, community setting)
• Drive engagement with high risk individuals (e.g., completed specialty appointments, adherence to Post discharge visits) may include accompaniment to appointments
• Assist with completion of applications to access eligible benefits
• Conduct wellness checks in home, participate in remote monitoring program education on individuals with specific health conditions
• Facilitate communication between all identified parties for the patient involved in care (e.g., family members, care givers, medical providers, community-based organizations)
• Partner with patients to identify their goals, increase engagement in care and reduce barriers to achieving healthcare goals and execution of their care plan
• Navigate Managed Care plans and resources to ensure mindful utilization
• Manage an assigned caseload while remaining in compliance with all internal and regulatory requirements (where delegated services are active)

• Collaborate with internal care teams as well as external healthcare professionals, patient social supports and insurance resources to assess the patient's healthcare needs and ensure successful outcome of care plan goals
• Scheduling, leading and maintenance of interdisciplinary care team (ICT) meetings (where delegated services are active)

• Conduct assessment(s) to identify individual patient needs and goals, develops a specific patient-centered care plan to address problems, sets goals and interventions as identified during the assessment
• Maintain HIPAA standards and confidentiality of protected health information
• Capacity to transport oneself to members' homes and facilities and comply with travel and mileage reimbursement policies
• Complete all activities and interventions outlined in the members care plan and ongoing monitoring of cases to ensure routine follow up and progression in their care plan goals
• Partner with Care Team throughout managed patients' inpatient and post acute episodes of care

• Maintain clear documentation of patient enrollment and progression through programs within compliance timeframes

• Practice in accordance with applicable laws and standards, and ethical principles
• Perform other job duties as requested by Care Management leadership team
• Participate in compliance audits of caseload (where delegated services are active)

What are we looking for?

• Bachelor's degrees and/or minimum of two years of relevant health care experience required
• Prior care coordination or case management experience
• Bilingual in Spanish or other languages spoken by people in the communities we serve, strongly preferred
• A problem-solving orientation and a flexible and positive attitude
• Experience utilizing electronic medical record systems
• Knowledge of community resources and resource navigation
• Experience with motivational interviewing, behavior change, health promotion, and coaching
• Knowledge of payer managed care programs preferred
• Strong verbal and written communication skills and customer service orientation
• Accomplished problem-solving skills and a highly flexible and accountable work ethic
• Experience working with multiple software platforms, electronic health records, google suite, including gmail and google documents, spreadsheet development and navigation, data processing
• Excellent organizational skills and ability to manage multiple priorities appropriately
• US work authorization
• Someone who embodies being "Oaky"

What does being "Oaky" look like?

• Radiating positive energy
• Assuming good intentions
• Creating an unmatched patient experience
• Driving clinical excellence
• Taking ownership and delivering results
• Being scrappy

Why Oak Street?
Oak Street Health offers our coworkers the opportunity to be at the forefront of a revolution in healthcare, as well as:

• Collaborative and energetic culture
• Fast-paced and innovative environment
• Competitive benefits including paid vacation and sick time, generous 401K match with immediate vesting, and health benefits

Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply to oakstreethealth.com/careers.