Company: Oak Street Health - 422 W McKinley Ave, Suite B, Mishawaka, IN 46545 Title: Community Health Worker Role Description The purpose of a Community Health Worker (CHW) at Oak Street Health is to act as the bridge between our patients, community, and medical systems in order to remove barriers and increase wellness across all life domains. A CHW is a patient's advocate or liaison, accompanying patients through proactive in-person and phone outreach based on their care needs to promote health literacy and increase access to resources needed to live healthier lives. High levels of flexibility, problem solving, strong communication, and an intimate knowledge of the community served are required to be successful. CHWs work closely with MSWs to manage patient care plans, support care team decision making, and coordinate clinical and complementary services needed to provide high quality health care and improve the quality and cultural competence of service delivery. CHWs are expected to work within their scope of practice. There is no expected clinical license for this position Check out this pamphlet for a sneak peek into the life of an Oak Street CHW! Core Responsibilities Include: * Establish and maintain strong interpersonal relationships with patients, community organizations, team members, and partners to coordinate patient needs * Manage patient referrals defined by the care team & collaborate with the Medical Social Worker on action plan * Facilitate communication between all identified parties involved in patients' care as needed (e.g., family members, caregivers, medical providers, community-based organizations) * Form relationships with and build an inventory of local community organizations that may benefit our patients * Connect patients to state and local community resources related to housing, transportation, food, and activities of daily living among other social and physical barriers to health. * Assist patients with completion of applications for accessing eligible benefits and resources * Promote goal setting and achievement to improve patients' quality of life and self efficacy with patients. Goal definitions are agreed upon by the care team * Meet with patients in patient-centered and patient-preferred locations (e.g., Oak Street Health center, patient's home, external medical provider facility, community setting) * Community Health Workers should plan to spend about half of their time outside of the center in patient-centered locations; this means having access to a reliable means of transportation to do so is required * Drive engagement with high risk individuals (e.g., completed specialty appointments, adherence to Post Discharge Visits) may include accompaniment to appointments * Complete referrals to organizations and agencies as needed * Deliver culturally appropriate health education in the areas where OSH has provided competency training to the CHW * Support care team decision making through participation in interdisciplinary team meetings * Document interactions with patients in electronic medical record in a timely manner while maintaining HIPAA standards and confidentiality of protected health information * Manage time, set priorities, work independently, and collaborate effectively with an interdisciplinary medical team * Other duties as assigned What we're looking for We're looking for motivated individuals with: Required: * Minimum of 1 year of experience in healthcare, community-based, case management, or social service environment * Strong oral and written communication skills * Ability to manage multiple priorities while maintaining a positive attitude * Dedication to serving the community and building meaningful relationships * Proficient computer skills (i.e. Windows, GSuite, Microsoft, etc.) * Access to reliable transportation and ability to travel throughout the community to various locations * US work authorization Strongly Preferred: * Fluency in language that is commonly spoken in the community when necessary. Most often this will include Bilingual English/Spanish * Experience working on multidisciplinary teams with organizations, agencies, patients, and community members * Knowledge of community resources and resource navigation Preferred: * Community Health Worker certification or Associates or Bachelors in a related field is a plus * Experience utilizing electronic medical record systems Other Skills * A problem-solving orientation and a flexible and positive attitude * 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 relentlessly determined Why Oak Street Health? Oak Street Health is on a mission to 'Rebuild healthcare as it should be'', providing personalized primary care for older adults on Medicare, with the goal of keeping patients healthy and living life to the fullest. Our innovative care model is centered right in our patient's communities, and focused on the quality of care over volume of services. We're an organization on the move! With over 150 locations and an ambitious growth trajectory, Oak Street Health is attracting and cultivating team members who embody 'Oaky' values and passion for our mission. Oak Street Health Benefits: Mission-focused career impacting change and measurably improving health outcomes for medicare patients * Paid vacation, sick time, and investment/retirement 401K match options * Health insurance, vision, and dental benefits * Opportunities for leadership development and continuing education stipends * New centers and flexible work environments * Opportunities for high levels of responsibility and rapid advancement Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply. Learn more at www.oakstreethealth.com/diversity-equity-and-inclusion-at-oak-street-health