Why This Role is Important to Us:

　　CCA's Acute Care Health Outreach Worker II (HOW) will provide patient navigation and support for patients with complex medical and social needs and disabilities and will report to the Medical Director of Acute and Urgent Care. The Acute Care HOW II will extend the CCA outpatient model of patient- centered complex care management to the acute care setting --in the Emergency Department (ED), hospital, and in the patient's home -- as a patient navigator, patient advocate, and program support for CCA's ED2Home team. The HOW II will focus on:

　　Providing patient assessments in the ED to help determine enrollment in the ED2Home program;

　　Navigating patients from the ED to home and conducting the care coordination required for a smooth and successful care transition;

　　Setting up patients in their home for ongoing medical management, including setting up technology in the home and teaching patients how and when to use it;

　　Conducting social needs assessments of patients, and then mapping discovered needs to appropriate resources in the community;

　　Building trust-based relationships with patients and the ED2Home providers;

　　Empowering and educating patients to help in self-management of their medical conditions;

　　Communicating with ED2Home and primary outpatient care teams to ensure thoughtful care coordination and transitions;

　　Developing an expertise in acute care patient navigation for complex care patients

　　The Acute Care HOW II is an essential component of the ED2Home team, helping the team to deliver high-quality, effective, and efficient patient-centered acute care CCA members in their homes.

　　Ideal candidate:

　　A CCA HOW who has been in a care partner or RRT role for 2+ years, knows the clinical systems and processes, and has a proven track record for providing Member support, advocacy, and follow-through

　　The candidate may be looking for additional responsibilities; e., this role can be considered an advanced HOW position

　　Has some hospital and/or acute care experience

　　A successful candidate will be able to:

　　Thrive in a fast-paced environment, is self-motivated and organized, has demonstrated ability to connect well and quickly with patients, and values impactful relationships with Members and fellow staff

　　Exude passion for the HOW role, and is seeking more responsibility and ability to impact patients' quality of life through direct care

　　Serve as a leader for an interdisciplinary team of clinicians involved in patients' care

　　Demonstrate empathy during patient encounters

　　Set healthy limits and parameters to develop successful working relationships with patients

　　The Acute Care HOW will report to the Medical Director of Acute & Urgent Care. The HOW will work in close collaboration with the hospital-based CCA team, consisting of a physician, nurse practitioner, and Transitions of Care nurse. The HOW will also communicate regularly and work with each patient's outpatient care team and outpatient HOW to ensure care continuity.

　　Provide clinical care to members via telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and care management services.

　　What You'll Be Doing:

　　Monday to Friday, 8 a.m. to 5 p.m.

　　Documents all clinical work in a timely manner and provides the necessary documentation required for data collection and billing purposes

　　Provides detailed sign out and information

　　Attends clinical team meetings and other mandatory educational sessions

　　Conduct needs assessment while patient is still in ED to evaluate potential for enrollment in ED2Home

　　Reviewing SDOH to help determine clinical pathway and assess for program success, including home safety, utilities (internet, electricity), nutrition, etc.

　　Guide an interdisciplinary team of clinical personnel (e.g., MD, NP, BH, VNA, PCA, etc.), managing the logistics and ED2Home infrastructure for assigned patients

　　Build longitudinal relationships (1-5 days) with patients, making them feel comfortable and supported and ensuring basic needs are being met

　　Contribute keen analytical skills, such as the ability to conduct root cause analyses and determine ongoing SDOH needs to guide care partners and the outpatient team

　　Participates in orienting and training new employees as required

　　Participates in quality assessment and quality improvement within CCA

　　Participates in annual clinical team retreats and social/teambuilding events

　　Maintains required professional credentialing and appropriate educational standards

　　Attends external meetings and activities as a representative of the organization as requested

　　Coordinate and complete pharmacy medication pick-up and deliveries for patients, at enrollment and ongoing as-needed

　　Coordinate DME needs, including placing authorizations in CMP, and coordinate delivery/pick-up

　　Serve as liaison for the patients' family, caregivers, or designated contacts

　　Serve as the point-of-contact for the patient: the HOW will be viewed as the Member's go-to "person" during the acute care treatment, providing support, care coordination, and navigation

　　Set-up, troubleshoot, and maintain technology in home environment

　　Conduct social needs assessments, mapping, and navigation

　　Oversee and manage the discharge checklist through member profile

　　Conduct co-visits with BH clinicians, NPs, paramedics, and other providers as needed, serving as bridge between patient and clinician

　　Travel between ED and patients' homes

　　Working Conditions:

　　COVID-19 vaccination is requiredWhat We're Looking For:

　　Qualifications:

　　Bachelor's degree required,Master's degree preferred

　　2+ years of progressive, relevant direct member/community collaboration to meet Social Determinants of Health experience in a health care environment

　　Proven skills and knowledge base, including knowledge of housing resources and community services, and judgment necessary for independent decision-making

　　Proficient in written and oral English communication

　　Excellent interpersonal skills, including integrity, good judgment, team work, and diplomacy

　　Ability to work quickly to deliver key support and interventions in a timely manner

　　Motivated individual who can self-manage

　　Willingness and capacity to assume responsibility for tasks

　　Ability to juggle many tasks concurrently and prioritize workload in an acute care environment with competingdemands and high expectations

　　Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.

　　English required, Spanish, Portuguese, Haitian Creole, Vietnamese preferred

　　EEO is The Law

　　Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

　　Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.