Community Health Worker - Specialty Clinics

About the role

The Community Health Worker serves as a trusted community-based liaison, navigator, and member support resource. This role supports patients and members by conducting in-home and community-based wellness visits, completing health risk assessments and follow-up, identifying barriers to care, connecting individuals to appropriate health care and social needs resources, and reinforcing care plan goals.

Responsibilities

• Conducts in-home, clinic-based, telephonic, and community-based wellness visits with patients/members as assigned.
• Completes health risk assessments, social needs screenings, and follow-up activities to identify barriers related to health care access, food, housing, transportation, medication access, safety, utilities, and other social drivers of health.
• Provides support, education, and reinforcement to help patients/members understand and follow their individualized care plans.
• Supports medication adherence by providing reminders, identifying barriers to medication access or understanding, and escalating concerns to the appropriate clinical team member.
• Aids patients/members with appointment reminders, follow-up care needs, preventive screenings, immunizations, routine checkups, and appropriate use of their medical home.
• Facilitates transitions of care after hospital, emergency department, or skilled nursing facility discharge by assisting with outreach, follow-up needs, appointment coordination, resource connection, and escalation of concerns.
• Connects patients/members to appropriate internal and external resources. Helps patients/members access community-based resources, including food assistance, housing support, transportation resources, utility assistance, financial assistance programs, and other social service supports.
• Assists patients/members with completion of forms, applications, resource referrals, and follow-up steps needed to access programs or benefits for which they may be eligible.
• Serves as a trusted liaison between patients/members, families, community organizations, health care providers, clinics, and social service agencies.
• Buils positive, supportive relationships with patients/members while promoting engagement, self-management, and active participation in health and wellness goals.
• Documents all encounters, outreach attempts, assessments, identified needs, interventions, referrals, and follow-up activities in the appropriate electronic system according to departmental expectations.
• Escalates concerns related to safety, unmet social needs, changes in health status, behavioral health concerns, medication concerns, suspected abuse/neglect, or barriers requiring clinical or social work intervention to the appropriate team member.
• Maintains current knowledge of community resources, health care services, payer resources, internal programs, and referral pathways.
• Works collaboratively and effectively within a team while also demonstrating the ability to work independently in community-based settings.

Qualifications

• High School diploma or equivalent
• Valid Driver’s License
• Completion of a Community Health Worker, Community Healthcare Worker, Community Health Education Resource Person, or similar curriculum within one year of hire
• CPR certification
• Medical Assistant, Certified Nursing Assistant, Patient Care Technician, Health Coach, Peer Support, or other health care/community health-related certification
• Experience working directly with patients, members, families, or community members to address barriers to care
• Experience with electronic health records or other documentation systems
• Experience supporting patients with chronic conditions, preventive care needs, medication adherence, transitions of care, or social drivers of health
• Experience conducting outreach, home visits, community-based visits, or field-based work

Skills

• Strong communication skills
• Comfort working independently in the community
• The ability to build trust with diverse populations
• Sound judgment in identifying and escalating concerns appropriately