Job Description

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Who We Are: Central City Health (CCH) has been serving the under-housed and at-risk population in metro Detroit since 1972, by providing integrated healthcare services. Our services include primary and pediatric care, dental care, behavioral and SUD care, supportive housing, and community re-entry services, to name a few. In 2024, our President/CEO, Dr. Kimberly Farrow-Felton received the esteemed Healthcare Hero Award from Crain’s Detroit Business honoring her exceptional contributions to the health and well-being of our community.



Our Mission: To achieve wellness in the community by providing an array of primary and behavioral health care, housing, and substance abuse services with dignity and respect. Our Core
Values: CCH is guided by a set of values in fulfilling our mission.


Some of our values include:

• An environment that supports health and recovery.
• Person centered principles in the delivery of care.
• An environment characterized by cultural sensitivity, integrity, teamwork and trust.
• A commitment to service excellence and continuous quality improvement.
• Persons served take both an active part in their treatment and the organization.
• An atmosphere of welcoming and accessibility to people seeking our services that assures “no wrong door.”

  You Get

• 14 Paid Holidays Annually.
• 18 PTO Days (less than 1 Year; 27 Days on 1st Year Anniversary).
• Benefit Coverage after 30 Days: Medical/Dental/Vision/Short-term Disability.
• Company-Paid Life Insurance.
• Retirement Savings 403(b).
• Tuition Reimbursement.
• Continuing Education Allowance

GENERAL DESCRIPTION
Central City Health is committed to enabling every member in our community to thrive by building a collaborative multidisciplinary healthcare team. The Community Health Worker (CHW) is responsible for increasing access to health care by helping members and their families navigate community services and adopt healthy behaviors. The CHW supports the medical/ behavioral health teams through an integrated approach to care management and community outreach. As a priority, activity will promote, maintain, and improve the health of patients and their families. Duties will include providing social support and informal counseling, advocating for public health needs, and providing community outreach to potential patients. The CHW is expected to understand mental illness and addiction and be willing and ready to engage with clients who struggle with these issues at all levels. The CHW is responsible for collaborating with the organization’s multidisciplinary healthcare team to provide a thriving integrated system of care.

RESPONSIBILITIES

• Ensures all actions, job performance, personal conduct and communications represent the organization in a highly professional manner.
• Conducts outreach and prevention education services, targeting individuals in need of housing, a medical home and/or with chronic disease.
• Performs comprehensive screening/assessment activities including health status, health risks and social needs factors; connects patients to relevant community resources with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing healthcare costs.
• Assists patients in gaining access to and navigating a primary health care medical home, behavior health services, dental, housing, and other community based social services.
• Works in collaboration and continuous partnership with chronically ill or “high risk” patients and their families, clinic/hospital/specialty providers and staff and community resources to promote timely access to appropriate care.
• Establishes trusting relationships with patients and their families while providing widespread support and encouragement.
• Creates and promotes adherence to the documented care plan, developed in coordination with the patient, primary care provider(s) and/or behavioral health provider(s).
• Provides ongoing follow up, basic motivational interviewing and goal setting with patients/families.
• Increases continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals.
• Collaborates with medical, dental, and behavioral health provider staff to manage overall patient health; understands the correlation between physical and behavioral health issues.
• Counsel’s members on interventions to modify behaviors associated with health risks.
• Provides ongoing assistance to members/family to increase their health literacy.
• Assists members with completing applications and registration forms.
• Conducts eligibility determinations, enrollments, and follow-up with uninsured or underinsured members; assists with PCP (Primary Care Provider) designations.
• Educates people regarding the hospitalization process and the importance of timely outpatient follow-up to reduce hospital readmissions.
• Facilitates patient access to appropriate medical and specialty providers; assists patients in connecting with transportation resources as indicated.
• Works closely with medical providers to ensure that patients have comprehensive and coordinated care. Follow up with patients should be continuous from initial identification through closure by means of phone calls, home visits and visits to other settings where patients can be found.
• Acts as a patient advocate and liaison between the member/family and community service agencies (i.e., schools, Department Human Services, hospitals, support groups, etc.). 
• Assures patients’ rights are always maintained.
• Possesses knowledge about community resources appropriate to the needs of the target population, 
• Provides case management/resource assistance as indicated.
• Records patient care management information in the EMR no later than 24 hours after patient contact.
• Participates in a multidisciplinary care team, identifies problems, and provides feedback to team members regarding a solution; contributes to the integration of services inclusive of primary care, behavioral health, dental services, and supportive housing, and IPS/Supportive Employment; serves as a resource to other providers and staff. 
• Takes part in performance improvement activities such as, quality assurance audits and Patient Centered Medical Home processes; participates in the development of agency policies and programs to assure FQHC (Federally Qualified Health Center), NCQA and other regulatory standards.
• Performs other duties as assigned.

EDUCATION AND EXPERIENCE

• High school diploma or GED required.
• Michigan Community Health Worker certification required.
• Current Michigan Chauffeur’s Driver’s license required; Candidates who do not have a chauffeur's license, may still apply but must acquire a chauffeur’s license within 30 days of employment. 
• Demonstrated ability to adhere to State of Michigan driving laws, evidenced by maintaining an insurable driving record in accordance with CCH commercial auto insurance carrier required 

“This is an outline of the primary responsibilities of this position. As with everything in life, things change. The tasks and responsibilities can be changed, added to, removed, amended, deleted, and modified at any time by the organization. Central City Health is an Equal Opportunity Employer committed to a culturally diverse workforce. We are committed to providing an inclusive environment based on mutual respect for all candidates and team members. All qualified applicants will receive consideration for employment without regard to race, religion, color, age, sex, national origin, sexual orientation, height, weight, marital status, gender identity expression, disability status, protected veteran, or other legally protected status by state or federal law. At Central City Health the health and safety of our employees is our top priority. Vaccination has been proven to play a critical role in combating COVID-19. As a result, Central City Health prefers that employees are fully vaccinated against COVID-19; however, it is not required.”

Central City Health will be recognized in the community as a premier provider of accessible comprehensive behavioral and physical health care, substance abuse services, and housing opportunities that lead consumers toward self-sustainability. Our mission is to achieve wellness in the community by providing an array of primary and behavioral health care, housing and substance abuse services with dignity and respect.Vision

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