Position Summary:

Under the leadership and direction of the Director of Population Health, and in collaboration with Integrated Care Team leadership, the ICT Community Health Worker plays a pivotal role in supporting care coordination functions, including but not limited to assessment and care planning for patients screening positive for Health Related Social Needs (HRSN), patient engagement strategies, and transitions of care management. The ICT CHW serves as a liaison between the ICT members and external community-based service providers as needed, based on the needs of the patients. The ICT CHW is committed to continuous professional development within its scope of practice, including acquires and maintaining certification and additional training as applicable. As a care coordinator, manages a caseload of patients and follow them longitudinally to facilitate care planning and achieve goals.

Job Responsibilities and Performance Standards:

HRSN Scr...