
DSNP Community Health Worker - Honolulu, HI
- Honolulu, HI
- $20.00-35.72 per hour
- Permanent
- Full-time
- Caseload management of 40+ DSNP aligned and unaligned members
- Establish contact with members within 30 days of referral, complete an initial Risk Stratification Assessment (RSA) with corresponding Individualized Care Plan (ICP), and engage members every 30 days (at minimum) thereafter for ongoing monitoring
- Educate members on preventive health care measures and health and wellness information related to disease processes
- Educate members on appropriate utilization of services based on need (i.e. PCP vs ER)
- Work with members to develop healthcare goals and identify potential barriers to achieving those goals
- Assess, plan and implement care strategies that are individualized by members and directed toward the most appropriate, least restrictive level of care
- Connect with relevant providers, programs and services
- Utilize motivational interviewing techniques to help members identify and understand their intrinsic goals and motivate members to engage in positive behavior change
- Communicate with all stakeholders and relay necessary health-related information to ensure quality coordinated care and services are provided expeditiously to all members
- Advocate for patients and families as needed to ensure the patient’s needs and choices are fully represented and supported by the health care team
- Use technology to obtain and document health-related information
- Research member-related health information using internal and external systems (may include medical records systems, claims systems, health information exchange, benefit and eligibility platforms)
- Participate in projects and initiatives to improve quality measures and member experience
- 2+ years of experience with direct engagement with members either by phone or through a face-to-face visit in a medical, community health, and/or social services setting
- Experience working with populations with complex medical, behavioral and social needs
- Experience working independently or as part of an interdisciplinary team and participating with multiple stakeholders to meet member needs and execute member health action plans
- Familiar with community resources and social service programs
- Proven skill in developing trust and rapport with individuals who may be disengaged from the health care system
- Proven skill in performing culturally appropriate engagement with members and developing a person-centered care plan that promotes the members’ individual health care choices.
- Reside in Hawaii
- Willing or ability to travel about 50% of the time in Hawaii
- Case Management experience
- Experience with or familiarity with discharge planning
- Experience with electronic charting
- Experience with coordinating community resources
- Background in managing populations with complex medical, behavioral and social needs
- Background in mental health or experience working with serious mental illness