Community Health Worker - Primary and Specialty Care (Pediatrics)

About the role

The Community Health Worker (CHW) is a core member of the integrated care team in Pediatric Primary Care, working with patients, parents, and caregivers to address developmental, behavioral, and health-related social needs. Under the direction of a CHW Supervisor and reporting to Pediatrics Primary Care Leadership (Chief of Pediatrics), the CHW engages children and families through education, care coordination, and community outreach — connecting them to primary and specialty care, behavioral health services, parenting resources, and social supports across NYC.

The CHW serves as a primary point of contact for caregivers, assessing strengths, needs, and barriers to care while helping families navigate systems, build self-management skills, and access community resources that address behavioral and/or social needs such as food insecurity, housing, and transportation.

We are seeking a compassionate, community-centered professional with lived experience and cultural knowledge to match the communities we serve. In this role, you will act as a trusted liaison between families and the healthcare system, helping patients set health goals, navigate services, and access the care and resources they need to thrive.

The position is part of TeamUp, a grant-funded initiative integrating behavioral health into pediatric primary care from birth through adolescence. CHWs are expected to take part in TeamUp activities and demonstrate strong collaboration and communication skills to function effectively as part of an interdisciplinary team.

Responsibilities

• Participate in ongoing education and specialized training to learn and maintain CHW skills
• Engage and recruit eligible patients and conduct clinical or community-based assessments and interviews to identify their health goals and needs
• Assess and address health, social and service-related needs of assigned/identified patients and create individualized, patient-centered, goal-directed care plans for each patient
• Utilize evidence-based engagement strategies, such as motivational interviewing (MI) and problemsolving techniques, to engage and maintain trusting relationships with patients and caregivers, and to assess for and monitor emerging needs for prevention, wellness, medical, and behavioral health care
• Support and motivate patients to achieve their health goals by coaching them through behavior change and identifying their strengths and community support systems
• Help patients connect to a PCP, specialist, community services and/or mental health services, attend medical appointments, and fill prescriptions; communicate with their care team to help coordinate care
• Assist patients with social needs such as food insecurity, housing issues, legal needs, insurance or other health care coverage or transportation and provide referrals and follow-ups, as needed (for example, helping patients fill out benefit applications or escorting them to community organizations to obtain needed services)
• Educate patients regarding available community services, health services, and patient rights; provide feedback from patients to facility leadership to inform quality improvement efforts
• Collect and track data to support achievement of patient-centered care plan using assessment tools, surveys, and logs, as appropriate
• Document each patient encounter in the electronic medical record and use other electronic systems in accordance with established policies and procedures
• Attend regular team meetings to discuss patients, update care plans; communicate with patients' PCPs
• Conduct home and community-based visits to assess patient needs specific to the home environment
• Serve as a liaison between the community and the health system by communicating patient experience to the CHW Supervisor and Program team
• Report regularly to CHW Supervisor for support and feedback; participate in program improvement efforts
• Perform other related CHW program tasks, as needed and perform duties in response to public health emergencies, when necessary

Qualifications

Minimum Qualifications: Three (3) years of full-time experience in counseling, community work or community health activities in a government agency or community organization engaged in providing community services to the public, assisting members of the community in obtaining community services or maintaining liaison with schools, community organizations or other government agencies for the purpose of providing assistance and obtaining participation and support for implementation of community or public service programs; or satisfactory combination of education and/or experience equivalent to the above. Study at an accredited college or university in Sociology, Psychology or other Behavioral Science discipline may be substituted for experience on the basis that thirty (30) semester credits are equivalent to one (1) year of experience. However, all candidates must have at least one (1) year of full-time experience as described above.

Skills

• Familiarity with email and internet usage and comfort learning new computer programs
• Experience with Microsoft Office (e.g., Word, Excel, and PowerPoint), Electronic Health Record, Epic, FindHelp and MyChart
• Must possess excellent communication, documentation, reading and writing skills
• Proficiency in a second language is preferred (e.g., Albanian, Arabic, Bengali, Cantonese, French, Haitian Creole, Hindi, Korean, Mandarin, Russian, Spanish, Urdu)
• Ability and willingness to conduct home visits and outreach activities within assigned borough(s) of NYC
• New York City residency (i.e., Brooklyn, Bronx, Manhattan, Queens or Staten Island)

Department preferences

• New York City residency (Brooklyn, Bronx, Manhattan, Queens or Staten Island) preferred
• Familiarity with email, word processing and Internet usage and comfort learning new computer programs
• Excellent communication and documentation skills
• Proficiency in speaking a language other than English, preferably Spanish, Haitian Creole, Mandarin, Bengali, Russian, Cantonese, French, Arabic, Hindi, Urdu, Albanian, or Korean
• Ability and willingness to conduct home visits and outreach activities within assigned borough(s) of NYC