Job DetailsLevel: ExperiencedJob Location: Magnolia Health Center 7037 Capitol St., Suite N100, Houston - HOUSTON, TX 77011Position Type: Full TimeSalary Range: $16.50 - $22.00 HourlyJob Shift: DayJob Category: Health CareThe Community Health Worker (CHW) serves as a trusted liaison and member of the integrated care team with a focus on diabetes prevention and the important lifestyle modifications needed to improve the health and well-being of the individuals and communities El Centro serves. Working closely with patients, families, and community organizations, this position serves as a bridge between healthcare providers and the community and promotes access to quality healthcare services. The CHW contributes to El Centro’s population health strategy and vision by addressing social determinants of health, promoting healthy lifestyle choices and supporting patient self-management and efficacy through culturally responsive education and coaching. Compliance Statement This position requires compliance with El Centro’s Compliance Program, including its Corporate Compliance, Patient Safety and Risk Management, and Quality Assurance and Performance Improvement Plans, Code of Conduct, and El Centro’s policies and procedures. Such compliance will be an element considered as part of the Community Health Worker’s regular performance evaluation.  Essential Functions Work closely with the integrated care team to identify and engage patients at risk for diabetes, especially those with risk factors such as obesity, hypertension and prediabetes. Assist in the building, execution and ongoing quality improvement efforts of wellness programs for patients and communities. Conduct outreach activities through avenues such as phone calls, text messages, community presentations, health fairs, home visits, and workshops to raise awareness about El Centro’s services and health promotion initiatives. Utilize managed care rosters to identify and engage individuals and families in the community who may benefit from our healthcare services. Maintain up to date knowledge of available community resources and facilitate referrals. Collaborate with community organizations, schools, and other stakeholders to establish partnerships and build strong referral networks. Assist patients in navigating the healthcare system by providing guidance on insurance enrollment, appointment scheduling, and accessing appropriate resources. Continuously seek out knowledge and education on public health principles, chronic disease prevention, health promotion and community-based outreach strategies. Conduct one one-on-one or group sessions to teach individuals about healthy lifestyle choices, disease prevention, and self-management techniques. Screen patients for social needs using approved assessment tools Reinforce provider recommendations by assisting individuals in setting health goals, developing action plans, and monitoring their progress toward achieving optimal health outcomes. Participate in integrated care team meetings and huddles Communicate patient needs and progress to the care team Collaborate with healthcare providers, case managers, and social workers to ensure seamless coordination of care, improve patient engagement, and reduce hospital readmissions. Maintain accurate and up-to-date records of patient interactions, interventions, and outcomes using the electronic health record system. Collect and document relevant data related to program activities, community needs, and patient outcomes. Compile reports and summaries to evaluate the impact of community health programs and identify areas for improvement. Participate in quality improvement initiatives by providing feedback and suggestions for enhancing service delivery. Ability to carry out other duties as assigned. QUALIFICATIONS Community Health Worker certification required. Bachelor’s level degree in social sciences or social services preferred. Knowledge of diabetes prevention principles and healthy lifestyle interventions. Must have had one year experience in connecting individuals and families to community resources and facilitating referrals to address social determinants of health. Must be able to demonstrate case management and care coordination skills, especially related to social determinants of health, including healthcare system navigation, public health, community resource linkage, documentation standards, and accurate data capture within the electronic health record (EHR). Strong communication, motivational interviewing and patient education skills with the ability to work effectively with diverse populations. Must meet standards of care as prescribed by the respective funding source. Bilingual in English and Spanish (oral/written) required. Must be able to travel occasionally and attend off-site meetings, seminars and events utilizing non-agency resources.
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