Community Health Worker II

About the role

The Community Health Worker II provides comprehensive care coordination and complex social case management for high-risk patients, including those experiencing homelessness. This role conducts proactive outreach, assesses Social Determinants of Health (SDOH), develops individualized care plans, manages ILOS program services, and connects patients to medical, behavioral health, housing, and community resources. The Community Health Worker II also serves as a SOAR Benefits Specialist, assisting eligible individuals with SSI/SSDI applications and related documentation.

While based at the MLK facility, travel between clinic and community-based locations is required to support patient outreach and program activities.

Responsibilities

• Conduct proactive outreach to high-risk patients and coordinate their care to ensure seamless navigation of health and social service systems.
• Develop personalized care plans based on assessments, addressing barriers to self-sufficiency and independence.
• Make referrals and provide follow-up support to connect patients with needed resources and services.
• Facilitate transportation services and support patients in overcoming barriers to accessing medical care and social services, including addressing logistical challenges, coordinating appointments, and assisting with application processes.
• Conduct client interviews to gather comprehensive data on medical history, socioeconomic status, and program eligibility.
• Evaluate and follow-up with patients to assess progress and hold them accountable for achieving goals.
• Assess social needs and provide individualized care plans that address social barriers.
• Complete interviews with individuals to gather information for SSI/SSDI applications.
• Gather medical records and other information to complete SSI/SSDI applications.
• Write SOAR Medical Summary Reports for individual applications.
• Accompany individuals to appointments at the Social Security Administration.
• Coordinate visits to medical doctors, psychiatrists, and other specialists to obtain evidence for the application.
• Maintain accurate records of all patients and manage case data in the Homeless Management Information System (HMIS) and other program systems as needed.
• Collect, analyze, and report KPI metrics and actionable insights to the Community Health Program Supervisor to support strategic decision-making and continuous improvement.
• Enter data into electronic medical records (EMR) systems and other tracking systems.
• Handle calls from patients and community partners regarding patient needs.
• Attend and actively participate in staff meetings.
• Perform basic administrative duties, including answering telephones, greeting patients, updating and filing records, completing forms, handling correspondence, and scheduling appointments.
• Promote and demonstrate Hope values: Gospel motivation, Prayer, Excellence, Stewardship, Patience, Thankfulness, Humility, Service, Dignity through Relationship, and Hospitality.
• Ensure compliance with all 19 Health Resources and Services Administration (HRSA) Health Center Program Requirements.
• Actively participate in and support quality improvement activities and clinical practice team efforts emphasizing patient-centered care.

Requirements

• One year of experience in case management or related experience.
• High School Diploma or equivalent (required).
• State of NV Community Health Worker Certificate (required).
• SOAR Certification (required).
• Community Health Worker II Certificate (preferred).

Skills

• Excellent organizational and time management skills, with the ability to prioritize tasks, manage multiple cases, meet deadlines, and maintain accurate documentation.
• Strong critical thinking, problem-solving, and decision-making skills, with the ability to assess patient needs, identify barriers, and develop effective solutions and care plans.
• Proficiency in technology and data management systems, including electronic medical records (EMR), Homeless Management Information System (HMIS), Microsoft Office applications, and other program-specific software.
• Ability to operate general office equipment, including computers, calculators, copy/fax machines, telephones, and other office technology.
• Excellent communication skills, both written and verbal, with the ability to effectively engage patients, families, community partners, and multidisciplinary care teams.
• Strong interpersonal and team-building skills, with the ability to collaborate effectively with clinical providers, behavioral health professionals, community organizations, and external partners.
• Demonstrated passion for community health care and serving vulnerable populations.
• Proven ability to maintain integrity, professionalism, and confidentiality in a fast-paced and high-demand environment.
• Proven ability to manage performance goals and support continuous quality improvement initiatives.
• Ability to interact with people from diverse ethnic backgrounds, ages, lifestyles, and special populations with sensitivity, respect, and cultural humility.
• Faith to believe that Hope is a ministry of God, exemplifying the love of Christ, and held and directed by the Holy Spirit.

Physical demands

• Occasional standing, walking, lifting, reaching, kneeling, bending, stooping, pushing, pulling, and lifting and/or moving up to 25 pounds.
• Frequent sitting.
• Manual dexterity.
• Good reading eyesight and vision for close work.
• Ability to communicate by speaking and hearing in person or on the phone.
• Ability to travel to various locations.

Pay

$21 - $28/hr

Schedule

• Full Time
• On Site

Location: North Las Vegas, Nevada