Community Health Worker

Job Description

Job Description

Salary: $23.08

Role Summary:The Community Health Worker (CHW) provides hands-on support to MI Choice participants with care transitions, community resource coordination, health education, and follow-up after hospital or nursing facility discharge. The CHW helps participants access services, understand care instructions, manage appointments and medication-related needs, and remain safe and independent in the community. This role works closely with the Supports Coordinator andmaintainstimely,accuratedocumentation of all participant contacts and interventions.

Responsibilities and Duties

• Assistparticipants who are re-enrolling in MI Choice, transitioning from a hospital or nursing facility, or otherwise needingadditionalhands -on support to safely remain in the community.

• Help participants access community resources and services, including housing, employment, benefits, transportation, and other supports that promote health, safety, and independence.

• Monitor Bamboo Health discharge notifications for nursing home or hospital transitions and complete required follow-up with participants to help ensure a safe,timely, and smooth return to the community

• Conduct required transition follow-up activities, including visiting participants at home within three (3) days of hospital or facility discharge to review discharge instructions, medications received, prescriptions that need to be filled, and the importance of physician follow-up.

• Complete follow-up contact within thirty (30) days of discharge to assess whether the participant obtained medications, followed up with the physician, and carried out discharge recommendations.

• Assistparticipants with scheduling appointments, obtaining medication refills, accessing skilled care or physician-ordered services, and coordinating the supplies and supports needed to safely remain in or return to their home.

• Provide practical health education, and skills training to support independence, including medication follow-up, understanding medical information, chronic condition self-management, communication, problem solving, and recognizing when to seekadditionalcare.

• Support participants withfallsprevention and home safety byobservingenvironmental risks, reinforcing safety recommendations, and communicating concerns to the Supports Coordinator for further follow-up.

• Help reduce avoidable hospitalizations and emergency departmentutilizationby reinforcing discharge plans, encouraging follow-up care, supporting medication adherence, and helping participants address barriers to care.

• Visit participants in hospitals or nursing facilities, as needed, to support discharge planning, help facility staffidentifytheappropriate SupportsCoordinator contact, andassistwith coordination when a participant is returning home or transitioning through temporary rehabilitation.

• Maintain close collaboration with the participants Supports Coordinator, promptly reporting participant concerns, unmet needs, medication discrepancies, changes in condition, and other issues affecting the participants care or independence.

• Responds to referralssubmittedby the Supports Coordinator and completesappropriate follow-upbased onidentifiedparticipant needs.

• Completetimely,accurate, and thorough progress notes documenting participant contacts, education provided, follow-up activities, needsidentified, actions taken, and outcomes, so the Supports Coordinatorremainsinformed of all interventions and findings.

• Hand-deliver participant waiver folders annually toCQARhome-visit participants.

• Other duties as assigned.

Required Knowledge,Skillsand Abilities

• Experience working with older adults, individuals with disabilities, or vulnerable populations preferred.

• Experience supporting participants during transitions of care.

• Preferred experience with Medicaid, waiver services, or long-term services andsupports.

• Experience with fall prevention education, health education, or resource coordination.

• Ability tomaintainconfidentiality and handle sensitive participant information appropriately.

• Basic computer skills and ability to learn required documentation systems.

• This position requires regular local travel to participant homes, hospitals, nursing facilities, and community locations to provide in-person support andcarecoordination.

• Valid drivers license, reliable transportation, and proof of insuranceisrequired.

Education and Experience

• High school diploma or equivalent required.

• Community Health Worker training or certificationpreferred.