Clinical Community Health Worker

ABOUT USA Specialty Path to Good HealthUpperline Health is the nation's largest provider group dedicated to lower extremity, wound and vascular care. Founded in 2017 with the ambitious goal of transforming specialty care, Upperline Health is a pioneer in bringing value-based care models into specialty care. Upperline delivers a more efficient path for patients to receive consistent and effective treatment for chronic illnesses.Triage is temporary.Treatment is transformative.Upperline Health providers coordinate patients' care among a team of specialists -- physicians, advanced practice providers, care navigators, pharmacists, dieticians, and social workers for integrated treatment that addresses patients' immediate and long-term health needs.We put patients at the center of value-based care. About the Clinical Community Health WorkerThe Community Health Worker (CHW) is a frontline member of the Upperline Plus care team, responsible for managing a panel of patients through in-home visits and facilitating virtual visits with a Nurse Practitioner (NP). This role bridges the gap between clinical care and the home environment, ensuring patients in rural and underserved areas receive consistent, coordinated, and accessible health care. The CHW serves as the "eyes and hands" for the NP, gathering information, supporting technology use, and building trusted relationships with patients and their families. What You'll DoHome Visits & Patient Panel ManagementConduct regular scheduled home visits to an assigned panel of patients, following a defined visit cadence based on patient acuity and care plan needsPerform basic health assessments during visits, including vital signs (blood pressure, pulse, temperature, oxygen saturation, weight), medication reconciliation, and home safety/environmental checksObserve and document changes in patient condition, living situation, SDOH needs/health disparity needs, or caregiver support, and escalate concerns to the clinical care team promptlyBuild rapport and trust with patients and families to support engagement in their care planFacilitating Virtual NP VisitsSet up and manage telehealth equipment (tablet, camera, connectivity devices) in the patient's home to enable real-time virtual visits with the NPAct as the NP's "hands" during virtual visits — assisting with physical exam maneuvers as directed (e.g., positioning a stethoscope or otoscope, guiding the camera), and relaying findingsEnsure patients are prepared for virtual visits (appointment reminders, gathering medications/records, addressing questions or anxiety about the technology)Trouble-shoot basic technical issues with telehealth devices and internet connectivity; escalate persistent issues to IT supportCare Coordination & DocumentationDocument all visit findings, vital signs, and observations accurately and promptly in the electronic health record (EHR)Communicate patient status updates, concerns, and care plan progress to the NP and broader care team on a regular basisHelp coordinate follow-up appointments, referrals, transportation, and connections to community resources (food assistance, home health, social services, etc.)Support medication adherence through education, pill organization assistance, and refill remindersPatient & Community EducationProvide basic health education on chronic disease management (e.g., diabetes, hypertension, COPD), health literacy support, fall prevention, and healthy lifestyle habitsEducate patients and families on how to use telehealth technology and when/how to reach the care team between visitsServe as a cultural and community liaison, helping the clinical team understand patients' home environment, social determinants of health, and barriers to care Qualifications of the Clinical Community Health WorkerHigh school diploma or equivalent; Community Health Worker certification (or willingness to obtain within 90 days of hire, where state-certified programs exist)Valid driver's license, reliable vehicle, and willingness to travel daily within a rural service area, including to remote or hard-to-reach locationsComfort using tablets, apps, and basic telehealth/videoconferencing technologyDemonstrated ability to independently research and identify local, regional, and national resources addressing social determinants of health (SDOH), including resources related to food insecurity, housing, transportation, financial assistance, utilities, healthcare access, and other social needsAbility to assess a patient's individual circumstances and social needs and determine which resources, programs, or services are most appropriate for their specific situationAbility to translate complex program requirements and social-service processes into clear, practical, and patient-friendly guidanceKnowledge of mandated reporting requirements and ability to recognize situations involving suspected abuse, neglect, or exploitation, provided by or observed in working with patientsAbility to appropriately document and communicate concerns while maintaining patient confidentiality, professionalism, and adherence to organizational policies and reporting requirementsStrong interpersonal and communication skills; ability to build trust with diverse rural populations. Ability to collaborate effectively with community partners/agencies and advocate for patients when navigating social service systemsAbility to work independently in the field with minimal direct supervisionPreferredPrior experience in home health, medical assisting, EMT/paramedic work, or community outreachBilingual/multilingual skills relevant to the service area's populationFamiliarity with EHR systems and basic clinical documentationExisting ties to or knowledge of the local rural community Physical & Work Environment RequirementsAbility to travel extensively by car, including on rural/unpaved roads and in varying weather conditionsAbility to lift and carry a telehealth equipment bag (up to ~20 lbs) and basic suppliesComfortable spending the majority of the workday in patients' homes rather than a clinical office settingFlexibility to adjust visit schedules based on patient availability and urgent needs What Success Looks LikePatients on the CHW's panel receive consistent, timely home visits per their care planVirtual NP visits run smoothly with minimal technical disruptionCare team receives accurate, timely updates that support proactive, coordinated carePatients report improved trust, engagement, and satisfaction with their care BenefitsComprehensive benefit options include medical, dental and vision, 401K and PTO.CompensationCompensation is commensurate to compensation for similar positions in the region and based on prior training and experienceJob Type: Full-time Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.