We are seeking a Community Health Worker (CHW), under limited supervision, will address the complex social and health problems of Medicaid patients. The CHW will work as part of the Johns Hopkins Post-Acute COVID-19 and Critical Care Team (JH PACT) to support patients with Long COVID as well as those recovering from non-COVID critical illness. The CHW will work in partnership with a Social Worker at the Johns Hopkins Bayview Medical Center, Department of Case Management, with additional oversight by the JH PACT Medical Director and Nurse Director. This position serves as the patient’s liaison ensuring that each patient has access to all the services to which they are entitled. Activities will include screening and enrollment for programs; patient mentorship; patient education; patient follow-up and reinforcement of treatment plan tasks; coordination of appointments and transportation; and patient location and engagement. The CHW fosters cohesive relationships not only with patients, but also with community partners and medical teams. This position works with an interdisciplinary team of physicians, nurses, Case Managers, Social Workers, Dieticians and other community health workers.

Specific Duties & Responsibilities

• Fulfills the day-to-day duties and responsibilities of a Community Health Worker with emphasis on education and support for Long COVID and Post-Intensive Care Syndrome.
  
• Interact with patients and care partners during in-person JH PACT clinic.
• Assess members’ health and social risk factors and barriers to care.
• Coordinate plans for identified needs with the healthcare team when appropriate.
• Connect members with appropriate community resources and motivate members to increase compliance with healthcare instructions 100% of the time.
• Complete documentation accurately and in a timely manner.
• Coordinate care and collaborate with the health care team to support patients recovering from COVID-19 and critical illness.
• Communicate patient risk and needs to the care team when identified during assessments.
• Communicates changes in patient status and needs to care team.
• Request professional assistance when necessary and alerts team member of urgent needs.
• Complete referral to the appropriate team member as needed.
• Establish effective relationships with referral and community resources.
• Document collaboration with internal and external sources.
• Routinely communicate with supervisor and case managers in a timely and appropriate manner.
• Act as mentor to patients and gives their feedback to supervisor.
• Act as a liaison and advocate for the patient to connect and navigate the health system.
• Access EMR and other systems to assess and coordinate health care needs.
• Assists in scheduling appointments as necessary.
• Educate patients about Long COVID and Post-Intensive Care Syndrome programs and benefits
• Use internal and external resources to assist patients with finding appropriate resource.

Facilitates the achievement of Value Based Purchasing and HEDIS measures for patients with Long COVID and Post-Intensive Care Syndrome

• Review worklist, caseloads and /or reports to identify patients.
• Identify barriers to care during assessments and assist with addressing them 100% of the time.
• Verify appointment compliance with patient or provider or per claims.
• Assist patients with scheduling transportation to appointments.
• Frequently makes reminder calls for appointments/transportation notification as necessary.

Assist enrollees with barriers regarding transportation to appointments (high risk) and to Value Based Purchasing/HEDIS measure appointments

• Screen transportation requests to meet the transportation policy criteria for the patient populations.
• Make referrals to local transportation assistance (i.e. MA Transportation) and/or assist with initiation of process for those who do not meet the transportation criteria.
• Enter transportation requests into the electronic database within one business day for those meeting the criteria.
• Complete transportation request forms and schedule transportation with appropriate transportation vendor.
• Follow-up on unsuccessful contact attempts based on established protocols.

• High School Diploma or graduation equivalent.
• Two years related experience. 
• Additional education may substitute for required experience, to the extent permitted by the JHU equivalency formula.
  

• Bilingual English/Spanish.
• Work experience with emphasis on social, community, or health-related activities.

Classified Title: Community Outreach Specialist 
Job Posting Title (Working Title): Community Health Worker   
Role/Level/Range: ACRO37.5/02/CC  
Starting Salary Range: $15.70 - $26.25 HRLY ($43,680 targeted; Commensurate with experience) 
Employee group: Full Time 
Schedule: M - F 8AM - 4PM 
Exempt Status: Non-Exempt 
Location: Johns Hopkins Bayview 
Department name: ​​​​​​​SOM DOM Pulmonary  
Personnel area: School of Medicine