Community Health Worker

About the role

Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach to kidney care. We believe patients living with kidney disease deserve the best care. We are committed to improving patient outcomes and improving quality of life by delaying disease progression, shifting care to the home, and accelerating kidney transplants. We help nephrologists focus on the right patients at the right time across the full care spectrum. We do this by providing them with the best-in-class interdisciplinary clinical resources, analytical insight and tools, and services to patients. We listen to the needs of our patients, our employees, and our client partners, continually working to push beyond the status quo in which the care system manages patients today.

Responsibilities

• Some responsibilities may vary based on specific patient programs; however, the primary duties of the Community Health Worker include:
• Patient Engagement & Outreach
• Conduct telephonic and virtual outreach to patients identified with high social determinants of health (SDOH) needs.
• Establish trust and serve as a primary point of contact for patients enrolled in the CHW program.
• Build culturally competent relationships that promote engagement, encouragement, and patient empowerment.
• Care Coordination & Navigation
• Serve as a liaison between patients, families, clinical teams, dialysis centers, and community-based service providers.
• Facilitate seamless transitions of care across care settings to support comprehensive, patient-centered care.
• Assist patients with enrollment in health and social services, including completing applications, paperwork, and required documentation.
• Support clinical staff by coordinating care activities, identifying resources, and addressing barriers to care.
• Social Determinants of Health
• Conduct comprehensive assessments to identify social, economic, cultural, and environmental factors impacting patient health.
• Recommend gap closures and contribute SDOH findings to individualized care plans to improve quality and health outcomes.
• Connect patients to appropriate resources, including housing assistance, transportation, food security, utilities, and community support programs.
• Resource Management & Follow-Up
• Guide patients in understanding and accessing available health and social services within Evergreen Nephrology and external organizations.
• Follow up on and track referrals and outcomes related to pharmacy services, durable medical equipment (DME), home care, and other supportive services.
• Assist with identifying, scheduling, and coordinating transportation for medical and community appointments.
• Build and maintain up-to-date resource inventories across service areas and multiple states.
• Member Advocacy & Support
• Advocate for patients by identifying barriers to care, addressing inequities, and ensuring appropriate interventions and support are provided.
• Suppor

Requirements

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Benefits

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