Community Health Worker, ID Program

Position Summary: The Community Health Worker will conduct culturally appropriate care coordination, health education and outreach activities in the health centers and within the community. The Community Health Worker will assist patients to access the variety of social and medical services they need to maintain their health. The Community Health Worker will collaborate with the ID Care Team and the patients’ primary care physicians to promote health and wellness and contribute to the goals and objectives of the patients’ care plans. Key Functions & Responsibilities Build trusting relationships with patients and families while providing encouragement, motivational interviewing, goal setting, and health education. Conduct patient intakes and assess medical, social, financial, insurance, and other barriers that affect access to and adherence with care. Manage an assigned caseload and provide follow-up from initial identification through resolution or closure. Coordinate internal and external medical appointments, referrals, and care transitions. Support HIV care, including re-engaging patients who are out of care or at risk of falling out of care. Support PrEP referrals and tracking in collaboration with the clinical team and community partners. Provide HIV, STI, and general health education tailored to patients’ needs. Assist patients with applications, enrollment, renewals, and recertification for Medicaid, Medicare, Maryland Health Connection, MADAP, pharmaceutical assistance programs, and other benefits or financial assistance programs. Review insurance coverage, medical needs, medications, and financial eligibility to help patients identify appropriate options. Address medication-access issues, including prior authorizations, appeals, pharmacy coordination, emergency fills, coverage gaps, travel overrides, and insurance transitions. Coordinate access to injectable medications, including prior authorization, pharmacy communication, clinic delivery, and resolution of delays or denials. Manage pharmaceutical assistance and manufacturer programs, including Gilead Advancing Access, ViiV Connect, manufacturer co-pay programs, and other medication assistance resources. Serve as a liaison among patients, providers, pharmacies, insurance companies, health departments, and community agencies to resolve barriers to care. Coordinate care for newly diagnosed patients with local health departments and support timely linkage to appropriate services. Follow up on referrals to Disease Intervention Specialists (DIS) and other public health programs. Connect patients and families with social and enabling services, including transportation resources, food assistance, housing, legal services, energy assistance, disability/SSI resources, childcare, employment and job-training resources, medical equipment, and other social determinants of health resources. Assist patients in obtaining durable medical equipment, such as…