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WICT Community Health Worker/Health Coach

    • Job Tracking ID: 512689-715789
    • Job Location: Madison, WI
    • Job Level: Mid Career (2+ years)
    • Level of Education: High School/GED
    • Job Type: Full-Time/Regular
    • Date Updated: December 18, 2019
    • Years of Experience: 2 - 5 Years
    • Starting Date: ASAP
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Job Description:

The Wisconsin Interdisciplinary Care Team (WICT) Community Health Worker/Health Coach (CHW) will be the vehicle for providing member-centered care management services for members with the highest needs in the community. This professional position addresses medical, behavioral health, and social determinant needs of Independent Care members, while promoting and maintaining their quality of care. This position reports to the Supervisor of SSI.

Duties and Responsibilities:

  1. Perform all duties in alignment with the DHS contract for Medicaid Managed Care Organizations, specifically regarding the WICT
  2. Conduct outreach and engagement activities that support patient continuity of care, including re-engaging members in care if they miss appointments or do not follow-up on treatment
  3. Conduct initial and periodic needs assessments, including assessing barriers and assets (e.g. social determinant needs and social support); member and/or family/caregiver preferences; language, literacy, and cultural preferences
  4. Identify available community-based resources and actively manage appropriate referrals, access, engagement, follow-up and coordination of services
  5. Conduct visits in the community to complete monthly face-to-face requirements, including health risk assessments, with identified members and assist in developing care plans appropriate to the identified treatment goals
  6. Actively monitors member's ability and willingness to engage in treatment regimens and finds alternatives or solutions to their needs
  7. Coordinates necessary services with ancillary providers and community agencies as appropriate to ensure member stabilization within the community
  8. Meets on a weekly basis with the iCare interdisciplinary team to collaborate and provide updates on the WICT caseload
  9. Assists Care Managers, Team RNs, and Intervention Specialists with monitoring and evaluation of member needs, including for prevention, wellness, medical, and specialist, behavioral health treatment, care transitions and social community service needs
  10. Maintains thorough and timely documentation in accordance with iCare's policies and procedures
  11. Educates members on appropriate use of medical services and preventive health guidelines

Experience and Skills:

  1. Current high school diploma or GED.
  2. Related health care or social work experience, including knowledge of mental and behavioral health. An understanding of the impact of social determinants (poverty, lack of food, social supports) on health.
  3. Ability and willingness to work in the community and directly with the members (i.e., home, shelter, facility)
  4. A personal vehicle, valid State of Wisconsin motor vehicle operator’s license and conformity with insurance coverage limits are required.
  5. Ability to effectively communicate thoughts, ideas, and information both orally and in writing.
  6. Ability to demonstrate flexibility, set priorities with daily demands and long-term work assignments and projects.
  7. Ability to analyze social, behavioral and medical issues, motivational-interviewing and patient engagement skills.
  8. Consistent follow through with planned interventions. Demonstrated ability to work independently with minimal supervision and to make independent decisions addressing member needs.
  9. Strong interpersonal skills and ability to effectively interact with members and coworkers from a variety of different backgrounds and experiences in a professional and courteous manner.
  10. Ability to work effectively as a team member and cooperate in achieving company goals.
  11. Ability to use a personal computer and capability of learning software applications of Independent Care.