Job Description:

About NYC Health + Hospitals:Empower Every New Yorker "” Without Exception "” to Live the Healthiest Life PossibleNYC Health + Hospitals is the largest public health care system in the United States. We provide essential outpatient, inpatient and home-based services to more than one million New Yorkers every year across the city's five boroughs. Our large health system consists of ambulatory centers, acute care centers, post-acute carelong-term care, rehabilitation programs, Home Care, and Correctional Health Services. Our diverse workforce is uniquely focused on empowering New Yorkers, without exception, to live the healthiest life possible.At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.Job Description:CHWs work with patients performing patient-centered, community health work in collaboration with interdisciplinary teams. CHWs help patients and their families through the transition process from inpatient admissions or ED visits back to the community with a focus on helping patients remain engaged in ongoing care and to overcome barriers to managing their health conditions. CHWs motivate and support individuals to achieve their health goals through facilitating ongoing connection to care and linking patients with supportive services in the community and within the health system. General tasks and responsibilities will include:Participate in ongoing education and specialized training to learn and maintain CHW skills.Engage and recruit eligible patients and conduct clinical or community-based assessments and interviews to identify their health goals and needs Assess and address health, social and service-related needs of assignedidentified patients and create individualized, patient-centered, goal-directed plans for each patient Support and motivate patients to achieve their health goals by coaching them through behavior change and identifying their strengths and community support systems Help patients connect to a primary care provider, specialty care providers, community services andor mental health services, attend medical appointments, and fill prescriptionsAccompany patients during medical appointments and provide in-person support during hospital stays as needed; communicate with their care team to help coordinate care Assess ability of patients to manage their chronic disease(s) and work with care team to connect them to appropriate education and monitoring programs Assist patients with social needs such as food insecurity, housing issues, legal needs, insurance or other health care coverage, or transportation and provide referrals and follow-ups, as needed (for example, helping patients fill out benefit applications or escorting them to community organizations to obtain needed services) Educate patients regarding available community services, health services, and patient rights; provide feedback from patients to NYC H+H to inform quality improvement efforts Collect and track data to support achievement of patient-centered care plan using assessment tools, surveys, and logs, as appropriate Document each patient encounter in the electronic medical record (Epic) and use other electronic systems (e.g., NowPow) in accordance with established policies and procedures Attend regular team meetings to discuss patient progress and update care plans; communicate with patients' primary care providers Conduct home and community-based visits to assess patient needs specific to the home environment Serve as a liaison between the community and the health system by communicating patient experience to the CHW Supervisor and Program team Report regularly to CHW Supervisor for support and feedback; participate in program improvement efforts Perform other, related CHW program tasks, as needed and perform duties in response to public health emergencies, when necessaryMinimum Qualifications:For Appointment to Level I 1. One year of full-time experience in a government agency or community organization in providing community services to the public or in assisting members of the community in obtaining community services; or 2. Completion of an approved six month training program of combined classroom training and on-the-job experience in community liaison work, plus six months of full-time experience as described in 1 above. For Appointment to Level II In addition to meeting the qualification requirements of Assignment Level I, appointment to Level II requires: 1. Two additional years of full-time experience in counseling, community work or community health activities in a government agency or community organization engaged in providing community services to the public, assisting members of the community in obtaining community services or maintaining liaison with schools, community organizations or other government agencies for the purpose of providing assistance and obtaining participation and support for implementation of community or public service programs; or 2. Education andor experience equivalent to 1 above. Study at an accredited college in sociology, psychology or other behavioral science may be substituted on the basis of 30 semester credits for each year of the experience described above. However, all persons must have at least one year of the full-time experience described above. For Appointment to Level III In addition to meeting the qualification requirements of Assignment Level II, appointment to Level III requires: 1. One additional year of full-time experience as described in 1 above. For Appointment to Level IV In addition to meeting the qualification requirements for Assignment Level III, appointment to Level IV requires: 1. One additional year of full-time experience.Department PreferencesExcellent communication and documentation skillsFamiliarity with email, word processing and Internet usage and comfort learning new computer programs. Bilingual is a plusAbility and willingness to conduct home visits and outreach activities within assigned borough(s) of NYC.Ideal candidate is familiar with communities served by NYC Health + HospitalsNYC Health and Hospitals offers a competitive benefits package that includes:Comprehensive Health Benefits for employees hired to work 20+ hrs. per weekRetirement Savings and Pension PlansLoan Forgiveness Programs for eligible employeesPaid Holidays and Vacation in accordance with employees' Collectively bargained contractsCollege tuition discounts and professional development opportunitiesMultiple employee discounts programs