Community Health Worker - Population Health

***Southwest Care Center employees can answer yes to these 3 questions:*** Do you want to make a difference? Do you believe everyone is entitled to quality healthcare? Do you desire to serve the underserved in your community? For over 25 years, Southwest Care Center has been providing exceptional healthcare to the communities of Santa Fe and Albuquerque, NM. We are a non-profit, FQHC-LAL providing medical, behavioral health, case management, community outreach, diabetes education, and pharmacy services. We are proud to offer gender equity medicine, syringe exchange, and HIV/HEPC testing and services within our communities. Southwest Care Center is currently seeking a full-time Population Health focused Community Health Worker in Santa Fe, NM For a Community Health Worker (CHW) in the Population Health Department of a Federally Qualified Health Center Look-Alike (FQHC-LAL), the essential duties typically focus on connecting patients to care, addressing barriers, supporting quality initiatives, and improving health outcomes for targeted populations. ***Practice Highlights:*** **Patient Outreach and Engagement** - Conduct outreach to patients identified through population health reports, registries, provider referrals, and care management programs. - Contact patients by phone, text, mail, or in person to facilitate engagement in care. - Re-engage patients who are overdue for preventive services, chronic disease management visits, immunizations, or follow-up appointments. - Assist with locating and reconnecting patients who have become lost to care. **Care Coordination and Navigation** - Assist patients in navigating healthcare services and understanding their care plans. - Coordinate appointments with primary care, behavioral health, dental, specialty care, pharmacy, and community-based services. - Support transitions of care following emergency department visits, hospitalizations, or specialty referrals. - Facilitate communication between patients and members of the care team. **Social Determinants of Health (SDOH) Support** - Screen patients for social needs such as food insecurity, housing instability, transportation barriers, utility assistance, and financial hardship. - Connect patients with community resources and social service agencies. - Assist patients with completing applications for benefits and support programs when appropriate. - Follow up on referrals to ensure needs have been addressed. - Population Health Initiatives - Support population health campaigns focused on preventive screenings, immunizations, chronic disease management, and quality measures. - Assist with outreach efforts related to UDS measures, PCMH initiatives, and value-based care programs. - Participate in care gap closure activities for targeted patient populations. - Maintain patient registries and work queues as assigned. **Health Education and Coaching** - Provide culturally appropriate health education regarding chronic disease management, preventive care, medication adherence, and healthy lifestyle choices. - Reinforce provider recommendations and care plan goals. - Encourage patient self-management and activation. - Promote health literacy and understanding of available healthcare services. - Documentation and Data Collection - Document patient interactions, outreach attempts, referrals, and outcomes in the electronic health record (EHR). - Maintain accurate records of community resource referrals and follow-up activities. - Assist with data collection and reporting requirements related to quality improvement initiatives. - Ensure documentation complies with organizational policies and regulatory requirements. **Care Plan Support** - Participate in interdisciplinary care team meetings and case reviews. - Assist with implementing patient-centered care plans developed by licensed clinical staff. - Conduct follow-up contacts to assess progress toward care plan goals. - Identify and communicate barriers to successful care plan completion. - Com…