CHRONIC CARE MANAGEMENT COMMUNITY HEALTH WORK
On-site · Hempstead, New York, United States
Job Summary
Chronic Care Management Community Health Worker (CCM CHW) serves as the liaison between patients and the care team to sustain monthly contact, reinforce care plans, and relay patient needs to the interdisciplinary team. Responsibilities include monthly telephonic outreach, enrollment in CCM services, identifying barriers to care, documenting patient interactions in the CCM framework, reinforcing care plans and self-management strategies, coordinating with providers and care managers, tracking referrals and follow-ups, supporting transitions of care (including post-discharge scheduling within 48 business hours), participating in monthly MDT meetings, and ensuring HIPAA-compliant documentation and adherence to regulatory requirements. Must possess strong patient engagement skills, ability to manage multiple patients, and effective communication with patients and care teams. Bilingual Spanish or Creole required.
Required Qualifications
- High School Diploma or equivalent required
- At least one year of experience in healthcare or case management is required
- Bilingual Spanish or Creole required
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