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Referral Services Assistant/Co...


Job Summary

Fort Worth, TX
Other/Not Classified
Job Type
Full Time
Career Level
Experienced (Non-Manager)
Job Reference Code

Referral Services Assistant/Community Health Worker CareMore Primary Care Fort Worth, TX #139868

About the Job


Your Talent. Our Vision. At CareMore, a proud member of the Anthem, Inc. family of companies specializing in providing senior Americans a complete and pro-active health care experience, it's a powerful combination. It's the foundation upon which we're creating greater care for our members, greater value for our customers and greater health for our communities. Join us and together we will drive the future of health care.

This is an exceptional opportunity to do innovative work that means more to you and those we serve.

Community Health Worker/Referral Services Assistant, CareMore Primary Care

What Is CareMore?

CareMore is entering a new growth phase, as a proven care delivery model for the highest-risk. We are a team of committed clinicians and business leaders passionate about transforming American healthcare delivery. We build and lead integrated, multi-disciplinary clinical teams to care for the most complex patients and currently serve over 150,000 patients in eight states across Medicare, Medicaid, and commercial populations. We strive for excellence and have achieved significant and measurable improvement in total cost of care, clinical outcomes, and experience. As an Anthem subsidiary, we benefit from the scale and resources one of America's largest managed healthcare organizations.

CareMore's Primary Care & Collaboration division oversees strategy, operations, and care delivery in our primary care markets (Iowa, Tennessee, Connecticut), where CareMore builds and runs capitated primary care medical groups and currently serves over 22,000 high-risk Medicaid and Medicare patients, as well as our collaboration with Emory Health System, which brings the CareMore model to over 20,000 Medicare Advantage patients in Georgia. The division also supports the development of new markets and models in the Primary Care & Collaboration area, including multiple new markets planned in 2018 and 2019. Our comprehensive approach to care includes extensivists managing acute and post-acute episodes of care, primary care clinicians, behavioral health clinicians, care management & engagement with case managers and community health workers, and mobile home-based care. We are continuing to evolve our model to effectively engage and care for complex patients and are building a team of passionate and execution-minded leaders dedicated to this mission.

You can learn more about CareMore's transformative approach to care here:

The Community Health Worker, CareMore Primary Care is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. As a member of the care management and engagement teams, the CHW is responsible for patient engagement, high risk patient accompaniment, community engagement, and improvement on social risk factors of health. A CHW also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy.

Core Competencies
  • A true patient-centered approach, from a bedside manner that puts patients and caregivers at ease
  • A collaborative team member and effective communicator
  • Willingness to operate in an ambiguous environment, without continuous supervision
  • Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization
  • Ability to write correspondence and communicate with members and community partners
  • Good organizational skills
  • Bi-lingual (English/Spanish), including the ability to translate Spanish to English for clinicians, is preferred
  • Good interpersonal skills
  • Basic computer skills

Essential Duties and Responsibilities

  • Maintains patient contact information data; maintain organized electronic records to track the status of patient contacts, next steps, and success rate
  • Responsible for a panel of patients for outreach and engagement telephonically and/or face to face, supporting longitudinally across care coordination and social needs
  • Conducts a range of call types to patients to support patient outreach goals: patient welcome visits, scheduling in support of Healthy Start visits and follow-ups; appointment reminders; appointment satisfaction follow-up calls; ongoing patient support and education calls
  • Attends community events relative to patient panel, in partnership with the community engagement manager
  • Demonstrates excellent customer service skills. Courteous, helpful, skillful care is to be demonstrated

to patients and their families, vendors, clinicians, and co-workers at all times

  • Utilizes available community, government, and/or patient resources needed to address patients limitations or support interventions in the management of chronic or behavioral health conditions
  • Assists patients to effectively utilize available resources to meet their personal health needs and help them develop their own capabilities for ongoing care needs
  • Provides guidance to patients seeking alternative solutions to specific social, cultural or financial problems that impact their ability to manage their healthcare needs.
  • Participates in care planning, case management rounds, and high-risk rounds for both medical and behavioral health patients. Collaborates with team members for patient management.
  • Will report to the Community Engagement Manager

Work Location & Travel Expectations

Based in local market with local travel.

    • High school diploma or general education degree (GED)
    • Minimum three years work experience in a healthcare setting and/or experience working closely with community and government organizations, or any combination of experience
    • Previous social work and/or community engagement experience is a big plus.
    • Proficient in use of Electronic Medical Record (EMR) and other technology use
    • Must be flexible with local traveling within the assigned county for daily home visits and covering assignments for teammates in case of emergency
    • Drivers License and reliable transportation
    • Optional: Bilingual (Spanish)

Anthem, Inc. is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine and is a 2017 Diversity, Inc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran.


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