UTHealth Houston Healthcare Transformation Initiatives is hiring a Certified Community Health Worker II (CHW) to join their remote team supporting the Transitions of Care Hub. In this position, the CHW will be managing reports, is well versed with scrubbing charts to identify patient barriers; facilitating communication and involvement in hospital discharge planning to ensure coordination of care between providers and clinical team members.

Preferred skills:

• Working knowledge of social determinants of health (SDOH) and their impact on patient recovery and readmissions.
• Experience analyzing hospital discharge and service reports to identify patients who meet criteria for care coordination programs (e.g., "the Hub").
• Proficiency in electronic health records (EHRs) and data systems used for patient tracking and documentation.
• Strong organizational skills with the ability to manage multiple priorities, follow-ups, and documentation.
• Excellent written and verbal communication, especially when working with patients, case managers, and cross-functional teams.
• Demonstrated ability to coordinate care conferences and team meetings, ensuring stakeholders are aligned and informed.
• Accuracy and attention to detail in documenting encounters and tracking service requests.
• Ability to manage multiple program-specific tasks and maintain consistent communication across various departments.
• Cultural sensitivity and ability to engage diverse patient populations with empathy and professionalism
• Familiarity with community resources and referral processes to assist patients with housing, food access, transportation, and related needs.
• Adaptable and proactive in a fast-paced, transitional care setting

Schedule: Remote / Monday - Friday, 8am - 5pm

What we do here changes the world. UTHealth Houston is Texas' resource for healthcare education, innovation, scientific discovery, and excellence in patient care. That's where you come in.

Once you join us you won't want to leave. It's because we reward our team for the excellent service they provide. Our total rewards package includes the benefits you'd expect from a top healthcare organization (benefits, insurance, etc.), plus:

• 100% paid medical premiums for our full-time employees
• Generous time off (holidays, preventative leave day, both vacation and sick time - all of which equates to around 37-38 days per year)
• The longer you stay, the more vacation you'll accrue!
• Longevity Pay (Monthly payments after two years of service)
• Build your future with our awesome retirement/pension plan!

We take care of our employees! As a world-renowned institution, our employees' wellbeing is important to us. We offer work/life services such as...

• Free financial and legal counseling
• Free mental health counseling services
• Gym membership discounts and access to wellness programs
• Other employee discounts including entertainment, car rentals, cell phones, etc.
• Resources for child and elder care
• Plus many more!

Position Summary:

Works in coordination with physicians, nurses and clinical care team members to effectively provide patients with internal and external resources, and deliver patient education to address and improve preventative and clinical quality care outcomes.

Position Key Accountabilities:

1. Establishes and maintains rapport with physicians, clinical and business staff and patients.

2. Responsible for conducting patient pre- visit planning procedures to identify gaps in care and reporting collected data and findings to the clinical care team to improve patient quality outcomes.

3. Gathers and documents demographic, insurance, health and social needs of patient to address barriers to care that may be affecting their medical condition.

4. Helps patients utilize resources in their area and assist with applications for eligible programs. Identify and build relationships with community organizations/resources.

5. Educates patients and their families of clinical care team roles, expectations of patient-centered medical home (PCMH) activities to manage their health conditions, and the importance of preventative health care. Motivate patients to be active, engaged participants in their health care.

6. Thoroughly documents patient encounter activities and follow up functions of resource distribution and referrals to resolve patient needs.

7. Maintains a comprehensive understanding of community needs, resources, services and programs available to advocate for patient needs and requests.

8. Continuously expands knowledge for professional growth and development to meet requirements to maintain State certification and skills competency that supports department goals.

9. Works to support the onboarding of new Community Health Workers (CHWs). Act as liaison between clinical staff and new CHWs as needed.

10. Plans, coordinates and facilitates applicable health and wellness programs. Contacts patient to schedule and/or reschedule clinical/wellness program visits.

11. Maintains confidentiality per HIPAA guidelines in regards to patient information. Adheres to all policies, procedures and standards within the organization.

12. Performs other duties as assigned.

Certification/Skills:

• Bilingual (English/Spanish) preferred
• Must have ability to perform complex and diverse administrative duties that involve application of procedures and demonstrate appropriate judgment within the CHW scope of work.
• Community Health Worker (CHW) by Texas Department of State Health Services (DSHS) required

Minimum Education:

High school diploma or GED.

Minimum Experience:

Three (3) years of related experience in health, social work or education. May substitute required experience with equivalent years of education beyond the minimum education requirement.

Physical Requirements:

Exerts up to 20 pounds of force occasionally and/or up to 10 pounds frequently and/or a negligible amount constantly to move objects.

Security Sensitive:

This job class may contain positions that are security sensitive and thereby subject to the provisions of Texas Education Code § 51.215

Residency Requirement:

Employees must permanently reside and work in the State of Texas.