ACO Community Health Worker

Meet patients in the health center and community settings, including hospitals and courts, to conduct outreach, follow-up calls, and transitional care management. Assess patient needs, strengths, and barriers related to housing, food, transportation, and behavioral health to develop and implement individualized care plans. Coordinate with primary care providers, nurses, and social workers while participating in team huddles and case discussions to reduce emergency department visits and hospitalizations. Document all interactions in electronic health records and advocate for patient needs within healthcare systems.