Community Health Worker

• Serve as a liaison between health and social services and the community
• Identify health-related issues, collect data, and discuss concerns with people served
• Support case management functions and address social determinants of health needs
• Improve self-management of chronic conditions and promote prevention and tailored health education
• Work with case managers, housing specialists, SDOH coordinators, ED Liaison, and Redetermination Specialist
• Conduct in-person assessments of member care needs, preferences, socioeconomic barriers, and home environments
• Assess barriers to healthy living and healthcare access; assist with physical and behavioral health appointment scheduling
• Advocate for members with providers, community resources, schools, and other entities
• Navigate healthcare and social service systems and coordinate access to housing, food, income, and transportation
• Promote care-plan adherence and provide motivational interviewing for medication and treatment adherence
• Provide social support and culturally appropriate health education and health coaching
• Attend Humana community events and provide education on case management services
• Conduct research and in-person outreach to locate difficult-to-contact members
• Assist with Health Risk Screenings and Welcome Calls
• Build relationships with providers and community resources and identify community resource gaps
• Support Humana's Readmission Prevention and ED Diversion program
• Perform other duties as assigned

• Conduct home visits with Aetna members with chronic conditions
• Reinforce care-plan adherence and adapt tasks to members’ culture, language, and religion
• Educate healthcare professionals and providers about social determinants of health
• Build relationships with members, providers, nurse case managers, agencies, supervisors, and office staff
• Reduce cultural and socioeconomic barriers between clients and institutions
• Assist with care-plan implementation, member education, care-management strategies, and community linkages
• Help members identify socioeconomic issues and develop health/social management plans and goals
• Identify care-system gaps and help members access community services and eligible programs
• Schedule social-service appointments and assist with applications
• Support medication adherence, medication reviews, and refill acquisition
• Teach disease self-management, including nutrition and symptom tracking
• Accompany members to appointments as needed
• Maintain electronic health records, compile reports, complete progress notes and letters, and perform administrative duties
• Travel extensively to client homes, community locations, agencies, and outreach destinations

• Serve as a bridge between Aetna members and the healthcare system through outreach and education
• Conduct home visits with members with chronic conditions and reinforce care-plan adherence
• Adjust services to members’ culture, language, and religion
• Identify healthcare needs, improve access to care, and reduce unnecessary hospitalizations
• Educate healthcare professionals and providers about social determinants of health
• Build and maintain relationships with members, providers, nurse case managers, agencies, supervisors, and office staff
• Reduce cultural and socioeconomic barriers between clients and institutions
• Assist with care-plan implementation, member education, and care-management strategies
• Link members to health and social services and help identify management plans and goals
• Identify care-system gaps and help members use community services, schedule appointments, and complete program applications
• Support medication adherence by reviewing medication lists and assisting with refills
• Teach disease self-management, including nutrition and symptom tracking
• Accompany members to appointments as needed
• Maintain member records in electronic health records, compile reports, complete progress notes and letters, and perform administrative duties
• Travel extensively to client homes, community locations, agencies, and outreach destinations
• Work under the direction of a designated professional

Community Health Worker – Field

• Serve as a bridge between Aetna members and the healthcare system through outreach and education
• Conduct home visits with members who have chronic conditions
• Reinforce care-plan adherence and adapt tasks to members’ culture, language, and religion
• Educate healthcare professionals and providers about social determinants of health affecting members
• Build and maintain relationships with members, providers, case managers, agency representatives, supervisors, and office staff
• Reduce cultural and socioeconomic barriers between clients and institutions
• Assist with care-plan implementation, member education, and care-management strategies
• Link members to health and social services and help identify socioeconomic issues affecting health
• Identify gaps in community care systems and assist members with community services, appointments, transportation vendors, and program applications
• Support medication adherence by reviewing medication lists and helping members obtain refills
• Teach disease self-management, including nutrition and symptom tracking/reporting
• Accompany members to appointments as needed
• Maintain member records in electronic health record systems and complete progress notes, letters, reports, and other documentation
• Travel extensively to client homes, community locations, agencies, and outreach destinations

• Conduct outreach and assessments; enroll patients and provide ongoing assessment and case management services
• Advocate for patients by identifying unmet needs and removing barriers to health and wellness
• Communicate with patients, document in medical records, and interface with medical providers
• Work in medical offices, specialists’ offices, hospitals, and patients’ homes with minimal supervision
• Assist in developing patient-centered care plans
• Connect patients with internal and community resources
• Serve as a liaison between community health and social service providers and Asian Health Services
• Collaborate with clinic staff, community members, and the multidisciplinary Care Neighborhood team
• Report suspected abuse and neglect as a mandated reporter
• Attend required AHS and CHCN meetings, training, and the Care Neighborhood patient support group RESPECT
• Meet departmental and Care Neighborhood documentation standards
• Build and maintain relationships on behalf of CHCN
• Participate in agency outreach, advocacy, events, quality improvement processes, and performance improvement teams
• Perform other duties as assigned

• Serve as a bridge between underserved communities and health and social service systems
• Work within the patient-centered medical home model and support chronic disease self-management
• Provide information and assistance to help patients navigate health and human services systems
• Advocate for patients and community groups and raise awareness of community health needs
• Build capacity for access to services and community engagement
• Engage patients in their own care using culturally sensitive, non-judgmental communication
• Collaborate on goal setting and care planning within an inter-professional team
• Give presentations to community groups
• Coordinate appointment attendance and individual plans of care
• Serve as a point person for issues and related solutions while maintaining appropriate boundaries
• Document assigned activities and support of community members
• Provide services under supervision as directed by state or regulatory requirements
• Adhere to patient privacy laws and the scope of duties; do not provide medical advice

• Serve as a bridge between underserved communities and health and social service systems
• Work within the patient-centered medical home model and support chronic disease self-management
• Provide information and assistance to help patients navigate health and human services systems
• Advocate for patients and community groups and raise awareness of community health needs
• Build capacity for service access and community engagement
• Engage patients in their care through non-judgmental communication and active listening
• Build relationships and work from a team-based perspective
• Collaborate on goal setting and care planning within an inter-professional team
• Give presentations to community groups using diplomacy and tact
• Coordinate appointment attendance and individual plans of care
• Serve as a point person for issues and related solutions while maintaining appropriate boundaries
• Empower patients to take an active role in their health care through effective problem solving
• Document assigned activities and support of community members
• Provide services under supervision as directed by state or regulatory requirements
• Strictly adhere to the scope of duties and never provide medical advice
• Adhere to patient privacy laws in health care settings and the community

• Remove barriers related to Social Determinants of Health, access to care, and access to needed healthcare services
• Serve as a bridge between members and the healthcare system through outreach and education
• Conduct face-to-face visits within Sarasota and Manatee Counties
• Help Aetna members attain and maintain better health outcomes
• Improve relationships between members and healthcare providers
• Support vulnerable members through an initiative addressing their needs

• Support carrying out treatment goals or care plans created by an advanced practice provider (APP)
• Assist patients in improving healthcare access and promote knowledge of health and behavior change
• Support patients with community referrals and arrange follow-up services
• Collaborate with APPs to develop patient treatment goals related to personal wellness, access to care, engagement with health resources and services, and self-management of conditions
• Respond to patient inquiries and assist with paperwork completion
• Facilitate remote visits between patients and providers using telephone or video conferencing
• Educate patients on care processes and provide counsel to reduce anxiety and fear
• Identify barriers to care, including financial, transportation, insurance, and language barriers, and refer patients to additional resources
• Provide transition of care support, health education, chronic condition management, and social services assistance
• Deliver services primarily in person in hospital and short-term rehabilitation settings, and in the community in person or telephonically according to patient preference and needs

• Support patients with navigating and accessing health and community services
• Carry out treatment goals or care plans created by advanced practice providers (APPs)
• Assist patients in improving healthcare access and promote knowledge of health and behavior change
• Support patients with community referrals and arrange follow-up services
• Collaborate with APPs to develop patient treatment goals related to wellness, access to care, engagement with health resources and services, and self-management of conditions
• Respond to patient inquiries and assist with paperwork
• Facilitate remote visits between patients and providers using telephone or video conferencing
• Educate patients on care processes and provide counsel to reduce anxiety and fear
• Identify barriers to care, including financial, transportation, insurance, and language barriers, and refer patients to additional resources
• Provide transition-of-care support, health education, chronic condition management, and social services assistance through a culturally relevant approach
• Provide services primarily in-person in hospital and short-term rehabilitation settings, and in the community in person or telephonically according to patient preference and needs