Transitions Clinic Community Health Worker

About the role

The Transition Clinic Community Health Worker is a 100% grant-funded, non-exempt position responsible for community-based outreach, reentry care navigation, patient engagement, health education, social drivers of health support, and care coordination assistance for individuals recently released from incarceration or otherwise justice-involved who are connected to Optimus Health Care and the Bridgeport service area.

Responsibilities

• Conduct outreach, engagement, and navigation for individuals recently released from incarceration or otherwise justice-involved who have chronic medical, behavioral health, substance use, and social needs.
• Support statewide reentry coordination for patients released from Connecticut DOC facilities or other justice-related settings when they are connected or expected to link to Optimus/Bridgeport services.
• Coordinate with DOC contacts, halfway houses, shelters, reentry programs, probation/parole contacts when appropriate, and community partners to identify eligible patients and support continuity of care.
• Recruit and engage eligible patients for the Transition Clinic program using program-approved outreach workflows and referral pathways.
• Aid patients with linkage to Optimus primary care and related services, including appointment scheduling, appointment reminders, visit preparation, warm handoffs, and follow-up after missed visits.
• Support care coordination for priority health areas, including HIV, hepatitis C, diabetes, hypertension, substance use disorder, mental health, medication access, preventive care, and primary care linkage.
• Provide health education and self-management support using non-clinical, culturally responsive, trauma-informed, and patient-centered approaches.
• Use motivational interviewing, harm reduction principles, and nonjudgmental communication to support patient goals, engagement, and readiness for care.
• Offer harm reduction and recovery support, including overdose prevention education, naloxone education/referral, MOUD/Sublocade linkage support, relapse-prevention encouragement, and referral to substance use treatment as appropriate.
• Aid with social drivers of health screening and stabilization needs, including Medicaid/HUSKY access, SNAP, identification documents, housing referrals, employment resources, food, clothing, phone access, transportation resources, and medication access.
• Coordinate transportation resources for appointments and services, including identifying barriers, helping patients schedule rides, confirming pickup and appointment logistics, and documenting transportation needs.
• Document outreach, patient contacts, referrals, barriers, follow-up, and care coordination activities in EPIC and/or other approved systems in a timely manner according to Optimus policy and program standards.
• Maintain recruitment logs, linkage outcomes, appointment attendance support, referral follow-up, outreach activity, patient engagement updates, and other program-defined grant tracking data.

Job Qualifications/Requirements

• Educational qualifications: High school level education; two years of related work experience and an associate’s degree; or a bachelor’s degree in a related field; or an equivalent combination of experience and education.
• Experience: Related experience in community outreach, peer support, reentry work, healthcare navigation, case management support, human services, behavioral health support, substance use recovery support, or social service navigation is required. Equivalent combinations of lived experience, community outreach, peer support, reentry work, healthcare navigation, CHW training, or related experience may be considered.
• Skills: Basic knowledge of chronic disease, reentry barriers, substance use recovery, mental health access, harm reduction, and social drivers of health. Ability to coordinate with healthcare providers, DOC contacts, halfway houses, shelters, community-based organizations, and social service agencies. Strong organizational skills, follow-through, reliability, attendance, time management, and ability to manage multiple patient needs and partner contacts. Ability to document clearly and professionally in EPIC and/or other approved systems and maintain program-defined grant tracking data. Comfort working in clinical, community, correctional, shelter, halfway house, and outreach settings when approved and appropriate.
• Languages: Bilingual English/Spanish strongly preferred. Ability to communicate with patients, staff, and community partners using tactful, culturally responsive, trauma-informed, and nonjudgmental communication in sensitive or emotional situations.
• Licenses/Certifications: Community Health Worker certification preferred but not required. If not already certified or trained as a CHW, willingness and ability to complete CHW training within the first 90 days of employment or within the timeframe approved by the supervisor.
• Other: Valid and verifiable Connecticut driver’s license, good driving record, and reliable transportation required. Ability to travel to Optimus sites, approved community locations, halfway houses, shelters, partner agencies, and DOC facilities when permitted and required. Ability to meet requirements for entry into DOC facilities and partner sites when applicable, including background checks, facility orientation, security clearance, and site-specific protocols. Ability to complete required Optimus, grant, compliance, safety, HIPAA, and program trainings.