Community Health Plan of Washington

Community Health Worker

• Serve as a liaison between health and social services and the community
• Facilitate access to services and improve the quality and cultural competence of service delivery
• Increase health knowledge and self-sufficiency through outreach, community education, informal counseling, social support, and advocacy
• Engage prospective care management program participants identified through data analysis and referral sources
• Provide community outreach services, including home visits
• Assist individuals with accessing transportation services
• Educate enrollees on healthy behaviors and community resources
• Provide telephonic and face-to-face follow-up with clients and service planning partners
• Coordinate reminder calls, medication, and medical appointments
• Assist care managers in securing and identifying referrals to medical, behavioral health, and social assistance providers
• Provide oral and written status updates regarding client alerts, progress, and needs
• Maintain case documentation according to policies and procedures
• Provide activities promoting socialization, recovery, self-advocacy, natural supports, and community living skills
• Increase enrollees’ knowledge of health conditions and improve adherence to prescribed treatment
• Travel throughout Pierce County and work in the field at least 50% of the time, with field visit appointments up to 75% of the time
• Perform other duties as assigned

Nurse

• Assist with and coordinate care management activities under the direction of an RN or LICSW Case Manager, Supervisor, or Manager
• Participate as an interdependent team member in member assessment, planning, facilitation, and advocacy
• Communicate with providers to arrange follow-up appointments and obtain clinical records
• Assist members with care coordination
• Coordinate member transportation and access to community resources such as food pantries and housing
• Coordinate and facilitate physical and behavioral health services within an episode of care
• Document and manage case identification, assessment, planning, goal prioritization, monitoring, support, and case closure
• Participate in clinical outcome data monitoring and collection
• Assess members’ medical, behavioral, and social health status, history, risks, gaps, and utilization
• Develop member-centric plans of care and interventions
• Provide behavioral health support and interventions to members in crisis
• Collaborate with PCPs, specialists, and community resources/vendors
• Document care coordination activities in the medical record system
• Support staff in answering member calls, including participation in the 5 p.m. crisis-call rotation
• Perform other duties as assigned

Clinical Care Coordinator, LPN/BSW

Bilingual

• Support CHPW’s Medicaid, Cascade Select, and Dual Special Needs Plan members in navigating benefits and healthcare systems
• Conduct new-member welcome calls and Health Risk Assessments
• Conduct routine outreach for annual Health Risk Assessments, health screenings, and Care Management program engagement
• Serve as a primary Care Team contact and triage inbound member calls
• Conduct telephonic outreach for welcome calls, satisfaction surveys, and Health Risk Assessments
• Educate members on benefits, screenings, program requirements, and Care Team engagement
• Schedule and coordinate in-home assessments and telehealth or in-person provider visits
• Conduct quarterly outreach to previously unreachable members
• Help members close care gaps and schedule appointments
• Triage and resolve calls from members, families, and caregivers, or refer them to appropriate staff
• Receive warm handoffs from internal teams for HRA or Care Team support
• Provide educational materials by phone, mail, or text
• Participate in Care Team meetings and interdisciplinary team conferences
• Refer members to appropriate internal programs and CHPW teams
• Access and manage medical records, upload documents, and maintain EHR episodes
• Close EHR cases for members no longer enrolled and notify assigned case managers
• Activate the Crisis Caller in Distress process
• Prioritize and complete daily tasks independently and collaboratively
• Perform other duties as assigned

Community Health Worker

Clinical Care Coordinator, LPN/BSW

Care Advocate, Bilingual Preferred