Mary's Center is a federally qualified health center that served over 31,000 men, women and children in 2012. We provide comprehensive health, dental, social, and education services to underserved, underinsured, and uninsured individuals in the D.C. metropolitan region. Our mission is to build better futures through the offering of these services. We embrace culturally diverse communites and provide them with the highest quality of care, regardless of ability to pay.

The Capital Clinical Integrated Network (CCIN) is a federally-funded project awarded to Mary's Center for Maternal and Child Health, Inc. by the Center for Medicaid and Medicare Services. Care Coordination teams, comprised of Registered Nurse Care Coordinators, Community Health Workers and in conjunction with Primary Care Medical Homes hope to achieve improved health outcomes and healthcare spending for program participants.

A Community Health Worker’s (CHW) role is to support the clinical activities and processes as charged by the RN Care Coordinators to ensure coordinated care and support for program participants. Responsible for recruitment of and outreach to program participants. Outreach activities will be conducted in homes, hospitals, neighborhoods, or other agencies. Connect identified participants (children and adults) in need of health and social services to their Primary Care Provider at each respective clinic. Perform assignments related to the service goals and objectives of the program as contracted.

Essential Duties & Responsibilities:

Include the following.  Other duties may be assigned.

A.    Core Roles of the CHW:

1. Cultural mediation between communities, and health and human needs
2. Advocating for individual and community services
3. Assuring people get the services they need
4. Informal counseling and social support
5. Building individual and community capacity
6. Providing culturally appropriate health education
7. Providing direct services
8. Health Education

B.  Coordination of Services/Program:

1. Recruits and maintains relationships with CCIN participants; completes home-based follow-up visits
2. Maintains calendar of appointments for all outreach activity and home visits and medical appointments for all enrolled participants
3. Performs medical screening using current technology and assigned equipment.
4. Responsible for time-sensitive documentation of home-based assessments, health screening and outreach activities in web-based care coordination system
5. Communicates patient-related needs and data to appropriate RN Care Coordinator and/or Primary Care Provider
6. Acts as liaison between patient, RN Care Coordinator and Primary Care Medical Home in resolution of problems, or referral of appropriate resource
7. Understands the "medical home" concept
8. Maintains a professional relationship with all community-based partners and federally-qualified health center staff 
1. Coordinates referrals with community-based organizations; works with various personnel to facilitate participant enrollment
9. Communicates to RN Care Coordinator any program updates/changes as they occur; works with RN Care Coordinator to improve identified deficiencies, and prioritize opportunities

1. Ability to perform outreach, collect data , and manage a case load of 30 participants
2. With Support from RN Care Coordinator, ability to create and monitor progress of patient-centered care plan for a case load of 30 participants

C.  Operational Duties:

1. Possesses knowledge of the organization’s requirements/systems/reports/processes in order to assist practices and program compliance
2. Possesses knowledge of internal programs, processes, and key contacts to facilitate appropriate referral and resolution of issues
3. Assists with and has an understanding of the referral process in reference to Primary Care Medical Homes as well as specialists who provide care to CCIN participants.

Competencies:

We define “competencies” as something that a person is capable of doing or being. Included in our definition of competencies are both skills and qualities. In this context, “qualities” mean personal characteristics or traits that can be enhanced but not taught. Patience, compassion, and persistence are examples of qualities. The word “skills,” on the other hand, is used to describe abilities gained through study or practice.

To perform the job successfully, an individual should demonstrate the following competencies:

• Community Leader
• Teamwork – Contributes to building a positive team spirit; Puts success of the team above own interests; Supports everyone’s efforts to succeed; Must be able to work well in multidisciplinary team setting
• Interpersonal Skills – Focuses on solving conflict in cooperative manner, not blame; Keeps emotions under control; Provide excellent customer service to our external and internal customers
• Communication/Organizational Skills - Proven effective written and interpersonal communication skills, well organized, ability to multitask and work independently, promote flexibility and teamwork. An effective CCIN CHW is a self-starter, takes initiative and has an attention for detail.
• Cost Consciousness
• Diversity – Shows respect and sensitivity for cultural differences
• Ethics – Treats people with respect
• Organizational Support – Follows policies and procedures
• Professionalism – Treats others with respect and consideration regardless of their status or position
• Safety and Security – Observes safety and security procedures; Reports potentially unsafe conditions; Uses equipment and materials properly
• Attendance/Punctuality – Is consistently at work and on time, which is pre-determined between the employee and the person(s) he/she reports to. Dependability – Follows instruction and responds to management direction; Takes responsibility for own actions; Commits to long hours of work when necessary to meet the needs of CCIN participants
• Flexibility - Must be willing to work nights and/or weekends.
• Computer Literacy: Strong PC skills, Microsoft Word, Microsoft Outlook, Excel, Database applications.

Education and/or Experience – Good knowledge of interviewing and recording techniques and some knowledge of health care systems. Second language desirable but not mandatory. High school diploma or G.E.D. Minimum 2 years working in a community-based oganization in a recruitment or an outreach capacity required. Knowledge of the surrounding community and available services in DC required. CHW program certificate of completion a plus.

Competency - Must possess demonstrated ability to relate to individuals and families of varied ethnic, cultural backgrounds, ages and economic circumstances. Excellent oral and written communication skills. Ability to apply professional public health principles, techniques, and basic sciences in homes and the community.

Responsible - Must be able to work independently and demonstrate attention to detail, accuracy and quality awareness. Ability to execute outreach plans, collect data and prepare reports.

Reasoning Ability –Proven analytical and problem solving skills. Ability to apply common sense understanding to carry out complex, multi-step instructions.

Physical Demands – Regularly required to sit; frequently required to reach with hands and arms; required to walk, stoop, kneel, crouch, talk or hear; must be able to lift objects up to twenty-five (25) pounds.

Work Environment – Administrative office setting; will need to travel to community-based, home, hospital or other community health center location. Valid Drivers License and personal vehicle is required. Quiet to moderate noise level. 

Equal Employment Opportunity- We are an Equal Employment Opportunity/Affirmative Action Employer and ADA compliant.

All your information will be kept confidential according to EEO guidelines.