Community Health Worker (CHW)

Description

The Community Health Worker (CHW) serves as the field-based extension of a physician-owned, value-based ambulatory primary care organization serving Medicare Advantage and Commercial PPO/HMO members across multiple California counties. Operating within a hub-and-spoke care model, the CHW works directly with patients in their homes and communities to support engagement, care plan adherence, social needs navigation, and access to healthcare services. The CHW partners closely with the Medical Director, Advanced Practice Provider (APP), Registered Nurse (RN), Pharmacist, and Care Navigators to help patients overcome barriers to care, improve health outcomes, and remain engaged in primary care services. CHWs conduct home visits, support collection of non-diagnostic health information, assist with technology and telehealth access, and connect patients to community-based resources.

Duties and Responsibilities

• Conducts home visits and community-based outreach to engage patients in care and support ongoing participation in the Care at Home program.
• Establishes trusting relationships with patients, caregivers, and family members.
• Identifies social determinants of health (SDOH) needs and barriers to care, including transportation, food insecurity, housing instability, social isolation, and technology access.
• Connects patients with appropriate community resources, social services, and support programs.
• Aids patients with scheduling appointments and accessing healthcare services.
• Supports telehealth visit readiness, including assistance with technology setup and patient education.
• Performs protocol-driven collection of non-diagnostic health information, including vital signs, weight, blood pressure, pulse oximetry, and other approved biometric measurements.
• Documents observations and patient-reported concerns and communicates findings to licensed clinical team members.
• Provides appointment reminders and follow-up outreach to improve care engagement and reduce missed visits.
• Serves as a patient advocate and liaison between patients, families, providers, and community organizations.
• Maintains accurate and timely documentation within the Electronic Medical Record (EMR) and other designated systems.
• Accompanies patients to appointments or community resource visits when appropriate.
• Participates in interdisciplinary care team meetings and case discussions.
• Maintains patient confidentiality and complies with all HIPAA and organizational requirements.

Qualifications

• High school diploma or equivalent required.
• Community Health Worker certification or formal CHW training preferred.
• Minimum one (1) year of experience working in healthcare, community outreach, social services, care coordination, or a related field preferred.
• Experience working with Medicare Advantage, older adults, or medically complex populations preferred.
• Bilingual English/Spanish preferred.
• Valid California Driver's License, reliable transportation, and proof of insurance required.
• Basic computer proficiency required; Electronic Medical Record (EMR) experience preferred.
• Demonstrated ability to work effectively with culturally diverse populations and communities.

About COPE Health Solutions

COPE Health Solutions is a national tech-enabled services firm powering success for health plans and for providers in risk arrangements. Our comprehensive NCQA certified population health management platform and highly experienced team brings deep expertise, experience, proven tools, and processes to improve financial performance and quality outcomes for all types of payers and providers. CHS de-risks the roadmap to advanced value-based payment and improves quality and financial performance for providers, health plans and self-insured employers. For more information, visit CopeHealthSolutions.com.

Benefits

As a firm passionate about health care, we’re deeply committed to the health and wellness of our own team members. We offer comprehensive, affordable insurance plans for our team and their families, and a host of other unique benefits, such as a yearly stipend for wellness-related activities and a paid parental leave program. You can learn more about our benefits offerings here: https://copehealthsolutions.com/careers/why-cope-health-solutions/.

To Apply

To apply for this position or for more information about COPE Health Solutions, visit us at https://copehealthsolutions.com/careers/open-positions/.