This position works with a designated clinical team to provide case management and support to patients in clinic and community settings. The CHW is responsible for addressing and removing barriers to improve patient care and health outcomes. This position serves as a link or liaison between the patient and the healthcare system and available social services. This position may be asked to provide staffing support for patient outreach and community-based events. This position may recruit for and teach assigned patient education opportunities.  This position requires a flexible, self-directed person, who is excellent at handling situations where all the details may not yet be available and can search for the information that is needed. Obtaining or maintaining Traditional Health Worker certification is required.

Patient Support & Case Management

• Build relationships and engage patients and their families of all ages, cultures and demographics with positivity, care, and respect while setting and maintaining professional boundaries
• Possess the ability to work independently and as a member of a team, working collaboratively with other Community Health Workers, nursing staff, medical and dental providers, and community partners.
• Assist patients and care team members in the development of care plans and patient goal setting
• Screen patients for social determinants of health (barriers) and connect patients to available health and social services resources to help them achieve health and wellness goals
• Stay well informed of available clinic and community-based resources, services and programs and eligibility requirements
• Assist patients in navigating the health and social services system by
  • Educating patients about services, eligibility criteria, enrollment processes
  • Provide scheduling and appointment coordination assistance
  • Teaching the skills and strategies to obtain care and self-advocate effectively, this includes helping patients overcome resistance to using available resources or services
  • Completing or reviewing paperwork necessary for service acquisition and financial assistance
  • Review assigned patient lists and contact patients to facilitate access to resources and services.
  • Seek solutions and services tailored to the needs of each patient
  • Facilitate continuity of care across the health and social services system by following up with patients to ensure needs were met, or to provide additional support, facilitate communication, or coordinate service delivery to avoid duplication of services.
• Deliver patient care within HRSA services scope and approved locations, encompassing patient homes, community-based sites, and providing home-based care when necessary and in adherence to defined services and safety protocols. Local travel required.
• Document in the electronic health record and other systems as required to fulfill expectations of documentation, coordination, and measurement

Community Outreach

• Build and maintain positive working relationships with healthcare entities, social service agencies and community-based organizations while representing Mosaic in and out of clinic
• Notify leadership of opportunities for community partnership or collaboration to benefit patient needs
• Attend and engage in community-based events as assigned, events are sometimes scheduled outside of usual working hours
• Attend community meetings as assigned

Patient Education

• Train and lead patient education opportunities (Ex: Walk with Ease, Living Well Series, etc.) as determined by program and patient needs.
• Schedule, recruit for, organize and prepare for teaching or assisting with patient education opportunities and classes as assigned.
• Teach basic concepts of health promotion and disease prevention as directed by nursing team.
• Provide support and encouragement to patients managing chronic illness as directed by nursing team.

Skills & Knowledge

Excellent communication and interpersonal skills. Strong, proven computer proficiency. Knowledge of community social service agencies and programs. Fluency in Spanish preferred.

Who We Are

Mosaic Community Health prides itself on being an innovative health system that pioneers unique and creative ways to provide and improve patient access to health care. Since our founding in 2002 we have proudly served insured and uninsured patients regardless of age, ethnicity, or income.

We focus on a holistic approach to patient care by incorporating behavioral health, pharmacy, and nutrition support to serve patients in the most meaningful way. At Mosaic Community Health, you will work with incredibly dedicated and mission-centered peers and be part of a dynamic team based environment.

Mosaic Community Health offers more than just a job, it is a lifestyle. A lifestyle of serving others. A lifestyle of being an integral part of your community. A lifestyle that offers work/life balance. A lifestyle of enjoying the outdoors! Central Oregon offers over 300 days of sunshine a year, so enjoy a PTO day on the mountain, biking/hiking trails, or the river! A lifestyle that improves lives, including yours. Of course, we also offer a great benefit package!