Job Description

Overview:

The Kidney Transplant Access Program is a partnership established to enhance data-driven kidney disease prevention, kidney care, and kidney transplant access by partnering across community, community-based organization, Department of Health, payors, and transplant center partnership to reduce disparities in kidney care access and outcomes.



The Kidney Health Community Health Worker overall role and responsibilities are to ensure that every patient is offered screening for social health related needs and is effectively connected to appropriate health and wellness resources, benefit programs, and other needed social services/community resources in a timely and culturally appropriate manner, with the goal of addressing social determinants that may lead to poor kidney care, hypertension, and diabetes outcomes. This role will also support optimizing patient chronic disease management and age and disease appropriate healthcare maintenance, including cancer screening.
Responsibilities:

Empower and Advocate

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Build trusting relationships with, and between patients, community members and providers to support patients' chronic disease, health maintenance, and kidney transplant needs. Conduct patient interviews to screen and assess social and service-related needs and partner with them to create individualized, patient-centered, goal-directed care plans. Act as a patient advocate and liaison between the patient, hospital system, community resources and community service agencies.

Community Mapping & Engagement:

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Participate in community initiatives to facilitate collaboration and networking, and advance health equity to reduce hypertension, diabetes, and kidney care disparities.

Advocacy and Outreach

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Use program data and experiences to speak publicly about program successes and barriers. Actively engage with a broad spectrum of stakeholders, including community and faith-based organizations, hospital leadership, and city and state officials, to build partnerships that support the health and well-being of our community.

Resource Connection:

Introduce and engage patients in OBH evidence-based hypertension, diabetes, chronic kidney disease, kidney transplant, and health maintenance care options. Outreach to CBOs to help patients access resources to address barriers to care (for example, helping patients fill out applications or escorting them to community organizations to obtain needed services). Research resources available to provide patients with accurate and reliable resources. Utilize digital resource directory platforms like UniteUs and FindHelp.

Collaborative Care:

Provide evidence-based counseling and support, individually and in group sessions, to patients with chronic conditions. Ensure that patients understand their treatment plan, lifestyle modifications and medication management. Facilitate communication between patients, community partners and providers. Provide culturally appropriate health information and translation. Participate in collaborative team, staff and patient care planning meetings. Assist patients with healthcare navigation, including coordination of patient appointments, transportation, social services, community support, access to health programs, referrals, and use of MyChart. Travel between office locations and to various community settings as required. Initiate and maintain regular contact with families, primarily in their homes (some evenings and weekends as necessary) and assist with chronic disease optimization, healthcare maintenance, and kidney transplant readiness, if eligible.

Documentation and reporting:

Manage database and data collection in electronic health record (EPIC) and Excel spreadsheets or other data systems. Run reports in the EHR on programmatic metrics. Perform other duties as assigned.

Qualifications:

Education

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High School Diploma, GED or equivalent required. Associate's degree in Community Health, Social Work, Human Services, Public Health, or any closely related field, highly preferred

Experience

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Minimum one (1) year previous experience in healthcare, community-based, or social work environment, required. Or, completion of a six (6) month training program, required. Familiarity with social service programs and Brooklyn community-based organizations. Experience providing direct support services to patients, experience with behavioral health needs a plus

Licenses / Certifications:

Community Health Worker Certificate, preferred.

Knowledge and Skills

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Bilingual English/Spanish or Haitian Creole a plus. Proficiency in Microsoft Office Suite, including Word, Excel, PowerPoint, and Outlook, with a demonstrated ability to apply these tools effectively in a professional setting. Ability to fully utilize OBH's electronic record systems, equipment and other healthcare systems relevant to this position. Excellent oral and written communication skills. Demonstrated commitment to working with underserved populations in a community setting. Displays high standards of ethical conduct and a commitment to equity. Ability to work with people of differing cultural, racial, sexual or ethnic identities. Displays sensitivity to the service population's cultural and socioeconomic characteristics. Ability to take initiative and willingness to learn. Ability to work well both in teams and independently. Commitment to a strengths-based, trauma informed approach to care. Strong motivational interviewing skills. Ability to collect and enter data for program management, evaluation and reporting purposes. Must be empathic, supportive, and patient.

Physical Requirements

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Position may require prolonged periods of standing, walking, talking, sitting, hearing, and bending throughout the work day. Position will be required to stoop, bend, lift, and carry items weighing up to 25 pounds. May include some repetitive motions.
Pay Transparency:
The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and can be modified in the future. When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., site, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity). Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The statements herein are intended to describe the general nature and level of work being performed by employees and are not to be construed as an exhaustive list of responsibilities, duties, and skills required of personnel so classified. Furthermore, they do not establish a contract for employment and are subject to change at the discretion of One Brooklyn Health (OBH). OBH is an equal opportunity employer, it is our policy to provide equal opportunity to all employees and applicants for employment without regard to race, color, religion, national origin, marital status, military status, age, gender, sexual orientation, disability or handicap or other characteristics protected by applicable federal, state, or local laws.