OUR VISION 

To continue as an eminent healthcare provider on Long Island, dedicating ourselves to providing exceptional health care for all our patients and to transform both the lives of the individual, and the community, for the better, one person at a time. 

OUR MISSION 

To provide access to equitable, optimal healthcare by improving the overall wellness of all individuals in our communities and delivering high quality comprehensive patient centered care. 

JOB TITLE:             Chronic Care Management Community Health Worker

REPORTS TO:         Assistant Director of Care Coordination

The following statements reflect the general duties, responsibilities, and competencies considered necessary to perform the essential functions of the job and should not be considered as a detailed description of all the work requirements of this position.

POSITION SUMMARY:

The Chronic Care Management Community Health Worker (CCM CHW) supports the Chronic Care Management program by serving as the key liaison between patients and the care team. This role focuses on maintaining consistently monthly patient contact, reinforcing care plans, and relaying patient needs and updates back to the interdisciplinary team. The CHW works under the guidance of providers and nursing staff to support patient engagement, self-management, and adherence to treatment plans.

RESPONSIBILITIES:

• Patient Engagement &Monthly Coordination
• Identifyeligible patients, introduce CCM services,and enroll in CCM programbyobtainingconsent.
• Conductconsistent monthly outreachtelephonically.
• Build rapport andmaintainongoing engagement with enrolled patients.
• Perform follow-up callsrelatedto chronic condition management.
• Identifyand escalate barriers to care (appointments, medications, social needs).
• Document all patient interactionsinaccordancewithCCM requirements.
• Care Plan Reinforcement
• Review Care Plans with patients to ensure understanding.
• Reinforce individualized goals, self-managementstrategies,and next steps.
• Identifybarriers to adherence and escalate concerns to the care team.
• Identifywhen updates are needed and notify providers.
• Medication and Self-Management Support
• Review medication adherencewithpatients (non-clinical).
• Support patients in understanding prescribed regimens and routines.
• Encourage chronic disease self-management techniques.
• Team Collaboration
• Participate in team huddles with providers and nursing staff.
• Receive direction and task prioritization from clinical and carecoordinationleadership.
• Maintain ongoing communication with assigned Nurse Care Manager.
• Care CoordinationFeedback Loop
• Coordinate care across providers,specialistsand community resources.
• Track referrals, lab results, and follow-up needs.
• Support transitions of care activities by following up with patients discharged within 48-business hours of notification andassistingwith scheduling post-discharge care.
• Focus on closing Gaps in Care (GIC).
• Participate in monthlyMultidisciplinary Team(MDT)meetings.
• Manage patient status andmonitorprogress towards health goals. 
• Gather and report patient updates,concerns,and barriers.
• Contribute to team-based strategy development for complex patients.
• Assistin implementing agreed-upon care strategies with patients.
• Documentation & Time Tracking
• Document CCM activities in the electronic health record (EHR).
• Trackaccuratetime spent on qualifying CCM services.
• Ensure documentation supports billing requirements.
• Quality & Compliance
• Ensure CCM services align with regulatory requirements.
• Participate in audits and quality improvement activities.
• Maintain HIPAA compliance.
• May be assigned other tasks and duties reasonably related tojobresponsibilities.

COMPETENCIES

• Possesses strong patient engagement and relationship-buildingskills.
• Managesmultiple patients and prioritizestasks effectively.
• Executesfollow-uptimelyand has strong organizational skills.
• Demonstrates strong interpersonal skills includingeffectiveoral, written, and telephoniccommunication with patientsand care team.
• Managestime efficiently and complete CCM activities consistently andtimely.
• Demonstratesinitiativeand presents as goal-oriented and accountable.
• Collaborateswith colleagues consistentlyandis able towork as part of a team.
• Documents activities andtrackstime accurately.
• Followsstructured workflows and compliance requirements.
• Identifiesbarriers to care andescalatesappropriately.
• Works effectively with providers,nursesand Care Team members as well asspecialists,hospitalsand community resources/agencies.
• Supports anddemonstratesteam-based care models within the Health Centers and within the Department.
• Adjuststo workflow changes and program needs.
• Understands cultural competency and displays empathy.
• Comprehends basic chronic disease management principles.
• Maintains opennessto feedback and continuous improvement.

 QUALIFICATIONS:

• High SchoolDiplomaor equivalent experiencerequired.
• Bachelor's degree in health-related field,Certified Medical Assistant (CMA), Certified Professional in Healthcare Quality (CPHQ)or similar certificationspreferred.
• At least one year ofexperiencein healthcareorcase managementisrequired.
• Experience working with patients with chronic conditions preferred.
• Working knowledge of computer software and electronic health records.
• Basic computer skills (Microsoft Office, data entry).
• Understandingchronic disease management concepts preferred.
• Familiarity with care coordination or population health workflows preferred.
• Bilingual Spanishor Creolerequired.

SALARY:  Commensurate with experience

MORE INFORMATION: This is a non-exempt position.  

PHYSICAL DEMANDS: 

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

While performing the duties of this job, the employee is regularly required to perform a range of physical activities that are essential to the core work functions outlined in this document.