IHC (Intensive Home Care) Community Health Worker

Devoted Health

Houston, TX, USA

Full time

Oct 27

This job is no longer accepting applications.

The Intensive Home Care (IHC) Program is at the heart of this goal: we are a highly collaborative, multidisciplinary team of physicians, nurse practitioners, case managers, social workers, and community health workers united by our mission to build a better care delivery system for Devoted’s most complex members. Through a mixture of in-home and virtual interventions, we provide whole-person clinical, social and logistical support for patients with complex chronic conditions, frail elders, and patients at high risk of hospital admissions.


The Community Health Worker (CHW) is vital to the success of the Intensive Home Care Team, playing a critical role in building trusting patient relationships and empowering patients to live healthy, dignified, independent lives. The CHW’s primary responsibilities include front-line patient advocate, community resource connector, care navigator & coordinator, and wellness and life skills coach, described in greater detail below. 


A day at Devoted could include:


Patient Advocate & Community Resource Connector

-Work with the IHC team to screen patients for Social Determinants Of Health needs & mobilize appropriate community-based resources

-Identify and catalog available community or national resources (i.e., transportation, financial, food, medication discounts, support groups)

-Perform a mixture of virtual, telephonic & field-based patient outreach, education & engagement visits

-Telephonic patient check-ins


Care Navigator/Coordinator

-Serve as Intensive Home Care’s “Care Traffic Controller,” working closely with patients’ PCP, specialists and the IHC team to facilitate and track resolution of clinical orders, such as scheduling appointments, diagnostic testing, DME, Home Health, and medical record needs

-Assist Intensive Home Care clinician, case manager, and social worker in reviewing patient panel needs and expediting/prioritizing key tasks such as scheduling follow-up visits, addressing STARs gaps, and getting

-Prepare for, and actively participate in, weekly Intensive Home Care Team Patient Rounds, helping the team to identify high risk patients, resource needs, and next steps

-Provide continuous administrative and outreach support for patients transitioning from hospital to home, ensuring a safe, smooth transition that meets HEDIS/STARs evidence-based transition of care requirements


Wellness & Life Skills Coach

-Reinforce patient education & care plans for acute and chronic conditions through virtual and field-based touchpoints

-Assist patients with practical skill development, such as how to use a pill dispenser, arranging community resources like Meals on Wheels, or showing someone how to complete needs-based paperwork

-Educate & motivate patients’ families and caregivers on patient needs to establish a sustainable support system

Attributes to success:

  • You love helping others improve their health and navigate a complex healthcare system with compassion, empathy, and warmth
  • You are comfortable performing care coordination for a predominantly elderly, complex Medicare population
  • You are able to ease the stress and anxiety of patients during difficult times 
  • You have a natural ability to successfully communicate and interact with different stakeholders in a patient’s life from doctors to pharmacies to nurses to caregivers
  • You are comfortable working with members over video and phone, but also in-person in their homes
  • Agility and collaboration are critical to your success - we are a new organization and have a start-up mentality 
  • You are comfortable engaging and learning new technologies including electronic health records (Athenahealth) and different computer platforms, operating systems and programs (Google Chrome, Google Sheets) 
  • You have a passion for supporting the delivery of healthcare that we would want for our own family 
  • You enjoy a fast-paced, high-energy, growing organization 

Desired skills and experience:

  • Bilingual preferred (English/Spanish) but not required
  • Geriatric experience or experience caring for an elderly or frail Medicare population
  • Health insurance experience, particularly Medicare Advantage
  • Prior experience working with complex patients and/or underserved populations

Skills and experience (must-haves):

  • Community Health Worker Certification, Certification of Medical Assistant (CMA),Registered Medical Assistant (RMA), or an Associates degree or higher in health sciences or related field and 5+ years’ work experience in a healthcare setting 
  • Two (2) years of clean driving record
  • Two (2) years of experience in outpatient medical care, with a bonus if you have experience with telehealth or house call visits
  • The ability to comfortably multi-task: you’ll be listening, talking and typing all at the same time.
  • Team player mentality with a can-do attitude
  • Comfortable working with internal and external stakeholders to advocate for our patients

#LI-SS1


If you love running towards complex challenges and transforming them into solutions, if you want to make a potentially huge impact on many lives, and if you are looking for a disruptive startup with an inspiring and talented team, Devoted Health may be the place for you! If you lack a specific credential for this position but believe that your strengths and life experiences will propel our mission, we would love to hear from you.


Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business.


As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.


COVID-19 Vaccination Requirement: Where permitted by applicable law, candidates must have received or be willing to receive the COVID-19 vaccine by date of hire to be considered. The Company will provide reasonable accommodations to qualified employees with disabilities or for a sincerely held religious belief, practice, or observance.

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