Community Health Worker

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Coordinates psychosocial care and services for patients as part of the multidisciplinary team in the ambulatory care setting.

  1. Identifies patients requiring care management and takes the lead as care Coordinator for those requiring intervention, especially with socially complex cases. Interviews patients and families to assess current strategies for self-care and available support systems to manage their health.

  2. Collaborates with the health care team to develop a psychosocial plan/support plan of care including but not limited to self-management activities, assuring appropriateness of services, assuring individualized support and education, determining the need for continued services, planning for care transitions and identifying and connecting the patient and families with available community resources as needed. Helps facilitate the safe care of patients, including facilitating the appropriate exchange of information among all caregivers.

  3. Participates in co-visits with providers using a multidisciplinary approach as needed.

  4. Serves as support to SCL Health for population management, patient self-management, along with support and tracking and intervening with high utilizers and those identified as medically at risk.

  5. Partners with community resources and community referrals sources as well as build new relationship with the direct community for patient care needs.

  6. Completes required documentation according to departmental standards.

  7. Participates in clinic and team Quality Improvement processes and patient safety initiatives. Identifies potential areas for improvement including processes that could be streamlined or revised to improve patient satisfaction and outcomes.

  8. Promotes mission, vision, and values of SCL Health, and abides by service behavior standards.

  9. Performs other duties as assigned.

Performs other duties as assigned.


Required: Associate's Level Degree

Preferred: Bachelor's Level Degree


Required: BLS

Preferred: LPN Accepted


Required : Three (3) years care management or social services experience. Previous work experience with sensitivity toward special populations, including those with limited education and non-English speaking individuals. Previous experience with managed care.

Preferred : Experience with applications such as MS Word and Excel preferred. Experience with EPIC medical software application preferred.

Knowledge, Skills, and Abilities:

To perform this job successfully, an individual must be able to perform each essential duty

satisfactorily. The requirements list must be representative of the knowledge, skills, minimum education, training, licensure, experience, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Able to travel within identified work area and perform interviews/visits in patient homes as needed.

Is self-directed, motivated and can function successfully in a team environment

Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served.

Demonstrates knowledge of the principles of growth and development over the life span and possesses the ability to differentiate the required care.

Organization: St. Vincent Medical Group, Billings, MT
Primary Location: MT-Billings/Surrounding Areas-Billings
Department: SVB PSO-SVPN-Care Coordination
Schedule: Full-time
Shift: Day Shift
FTE: 1.0
Job Number: 18001621
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