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.

CCIN works with chronically-ill patients who do not seek regular medical care at a health home, but instead use costly services such as emergency department visits. Care Teams led by nurses and staffed by Community Health Workers (CHWs) will identify target patients, create care plans for them based on data analysis, connect them to medical homes to facilitate and manage their care, and assign individual CHWs to work with each patient to support adherence to the care plan, particularly relating to controllable chronic conditions such as diabetes, hypertension and asthma.

A Community Health Worker’s (CHW) role is to support the clinical activities supervised by the RN Care Coordinators to ensure coordinated care and support for CCIN participants. Responsible for the recruitment of and outreach to CCIN participants. Outreach activities will be conducted in homes, hospitals, and neighborhoods. Connect identified 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:

Other duties may be assigned.

A.    Core Roles of the CHW:

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

B.  Coordination of Services/Program:

1. Performs home visits to recruit and maintain relationships with CCIN participants; completes community and home-based follow-up visits
2. Performs community-based outreach activities including attending community events, and working with referring providers in a clinical setting
3. Reaches out to potential participants via telephone, unscheduled home visits and direct mail campaign
4. Maintains calendar of appointments for all outreach activity and home visits and medical appointments for all enrolled participants
5. Performs medical screening including blood pressure and blood sugar screening
6. Responsible for time-sensitive documentation in web-based care coordination system
7. Communicates patient-related needs and data to appropriate RN Care Coordinator and/or Primary Care Provider
8. Acts as liaison between patient, RN Care Coordinator and Primary Care Medical Home in resolution of problems, or referral of appropriate resource
9. 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
10. 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

Competencies:

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

• An effective CCIN CHW is a self-starter, takes initiative and has an attention for detail.
• 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.
• 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 – High school diploma or G.E.D. Minimum 1-2 years working in an outreach capacity as a Community Health Worker, Family Support Worker or Health Educator. Competency in motivational interviewing, active listening and strength-based language. Strong knowledge of the surrounding community and existing resources. Spanish-fluency preferred but not mandatory.

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. Strong competency in typing and data entry skills.

Responsible - Must be able to work independently and demonstrate attention to detail, accuracy and quality awareness.

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

Physical Demands – The role of the Community Health Worker requires the ability to be on your feet frequently and be comfortable in participant’s home. 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 –Will need to self-manage time and competing priorities to travel to community-based, home, hospital or other community health center location. Quiet to moderate noise level. Must have a valid driver’s license and personal transportation.

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.