Skills for Rhode Island's Future (Skills RI) is recruiting Community Health Advocate for Providence Community Health Centers, Inc. Please read more about Skills RI at the end of this job description.

COMPANY: Providence Community Health Centers, Inc
JOB TITLE: Community Health Advocate
LOCATION: Providence, RI
HOURS: Full-Time

Under the direct supervision of the Supervisor of the Community Outreach Advocates, the Community Outreach Advocate (COA) will work in collaboration with the primary care team to identify and remove barriers to close gaps and to facilitate patients in obtaining quality health care. This position supports all case management programs across all sites, as well as other Accountable Entity related initiatives.

Key Responsibilities:

• Independently prioritize workload and outreach
• Work independently to maintain timely, accurate records, documentation
• Balance new referrals and actively engaged patients to stay within outreach timelines
• Assess patient/caregiver social determinant of health need through SDOH screening tools
• Assess depth of SDOH need based off assessment specific to the identified need; evaluate other SDOH needs that may not have been originally detected by the referral source
• Identify patient/caregiver barriers to health equity/access to appropriate care/adherence to provider recommended care
• Educate patient on COA services and assess the patient’s willingness to engage
• Utilize critical thinking to ensure referrals to and/or collaboration with the appropriate clinical team members occurs in a timely fashion
• Develop a culturally appropriate patient-centered plan of care that includes SMART goals
• Complete appropriate timely follow-up and care coordination within timeline expectations and in accordance with the plan of care
• Maintain an active caseload that includes patients/caregivers requiring ongoing support to reach goals
• Maintain detailed records related to patient engagement, collaboration, and coordination activities in the electronic health record
• Assess patient/caregiver knowledge and barriers to facilitate transitions of care from facility to home/community setting; connecting to appropriate resources and/or clinical supports to reduce readmissions and avoid ambulatory condition ER visits
• Complete and document medication history using patient/caregiver responses and PCHC approved tools
• Complete screenings per program requirements (i.e. PHQ, CAGE, GAD, HRA, SDOH, etc.)
• Support chronic condition management with PCHC protocols related to, but not limited to, diabetes, cardiovascular, and/or asthma checklists
• Perform remote patient monitoring enrollment and follow up procedures within the scope of the COA
• Perform pre-visit planning for patients engaged in designated programs
• Perform closure of quality gaps per standing orders and procedures
• Provide home find and home tenancy interventions
• Assist, identify resources, and/or teach patients with complex barriers that are engaged in COA programs to schedule and track appointments
• Assist, identify resources, and/or teach patients with complex barriers that are engaged in COA programs to utilize transportation services
• Assist, identify resources, and/or teach patients with complex barriers that are engaged in COA programs to overcome language barriers
• Educate patients on the proper use of the health care system (i.e. PCP availability, express care, urgent care, ER, 24-hour on-call provider, same day access, BH Links, Kids Link, etc.)
• Support interpretation with patients for other care management staff that do not speak the patient’s language
• Support translation of care plans for patients
• Work independently with patients to help patient develop their self-management skills and successfully meet care plan goals
• Provide information to patients about community resources and help patients access resources
• Utilize motivational interviewing skills and other patient engagement techniques with patients and caregivers
• Act as an advocate for patients/caregivers to support the patient centered plan of care
• Participate in interdisciplinary care team meetings/case conferences
• Attend assigned site meetings as identified by the COA supervisor
• Take personal responsibility for professional development and maintenance of certifications, which can include specialty trainings offered by the RIDOH and CHWARI
• Attend community meetings as identified by the COA supervisor such as patient resources/supports and professional support; this may occur outside of normal work hours
• Track and document referrals made on the patient/caregiver’s behalf using PCHC approved technologies (such as use of Unite US platform and/or the EHR)
• Outreach and engage patients/caregivers into ad hoc programs such as, but not limited to, the prescription produce/food as medicine program initiatives, legal resource classes, health eating habits classes
• Help patients with literacy barriers, this may include, but not limited to helping with navigation to complete applications if other community resources to do so are not available
• Represent the organization with a positive, professional attitude when communicating with patients and visitors of the health center
• Work well with others and can discuss in a professional manner any issues that come up with other staff
• Attend team meetings and read meeting minutes to establish an understanding for the content; it is the COAs responsibility to establish understanding of what occurred in the meeting if they are unable to attend
• Adhere to a predictable schedule as outlined in the offer letter
• Support community awareness around public health crisis, resources, and access to (i.e. COVID or Flu testing & vaccines)
• Support tracking and reporting of success stories
• Support tracking and reporting of qualitative data related to patient barriers, care, and services provided
• Adhere to HIPAA regulations
• Support precepting new staff
• Participate in departmental team building activities
• Home and community visits required per program procedures
• Accompanying patients to appointments after review and evaluation with supervisor or director for select high risk cases when patient is engaged with and/or known to a case management team member
• Unannounced home/community visits after review and evaluation with supervisor or director for select high risk cases when patient is engaged with and/or known to a case management team member; must be accompanied by a peer or supervisor
• Bill appropriately for services provided while assuring documentation to support billed services
• In addition to the organizational EHR, required to document in other PCHC approved systems such as, not limited to, UniteUs, HMIS, etc.

• Associates degree in Social Work, Human Services, or Community Health/Health Promotion, plus 2 to 3 years’ related experience is required. Bachelors degree preferred.
• Prior experience as a Certified Community Health Worker (CCHW) Accreditation is preferred. Certification required within 18 months of hire.
• Valid driver’s license with reliable transportation and proof of minimum auto insurance required
• Bilingual Spanish/English a plus

HOW TO APPLY
For more information and a full job description, please visit Skills for Rhode Island’s Future website at www.skillsforri.com/jobs. Applicants interested in this position will be screened by Skills for Rhode Island’s Future and Providence Community Health Centers, Inc will make the final hiring decisions.

WHY APPLY THROUGH SKILLS FOR RHODE ISLAND’ S FUTURE
Our mission is focused on supporting unemployed and underemployed job seekers. Our goal is to get you back to work. Skills for Rhode Island’s Future’s team will guide and provide you with support throughout the hiring process.
Skills for Rhode Island’s Future has agreements with employers to recruit talent like you, making us a resource to get the unemployed and underemployed job seeker back to work.