Job Description

Job Description

Job Description

Position Summary: As an integral member of our Patient-Centered Health Home (PCHH) care team, the Community Health Worker (CHW) utilizes unique expertise to bridge the gap between clinical care, social services, and patients. Working directly within a multidisciplinary care team, the CHW conducts proactive outreach, facilitates care coordination, and provides health promotion services. This role focuses on closing care gaps, improving clinical outcomes, and optimizing the cost-effective use of healthcare resources through patient empowerment and social support navigation.

Key Responsibilities: 

• Meet regularly with the care team to plan patient care, discuss active cases, and exchange clinical and non-clinical information as part of the daily practice routine.
• Conduct strategic outreach to actively engage patients in healthcare services and preventive care, successfully closing care gaps.
• Assist with the entry, navigation, referral, and tracking of both clinical needs and community social supports.
• Provide culturally appropriate education on health conditions and practical strategies to implement treatment plans and care goals.
• Educate, coordinate, and provide access to chronic disease management, including teaching self-management support and training patients on self/home disease monitoring.
• Facilitate collaborative goal setting with patients, assess their self-management plan progress, and assist directly with medication or treatment adherence.
• Work closely with patients to problem-solve and overcome daily obstacles to complying with a given clinical treatment.
• Co-lead health education groups and actively implement targeted wellness and prevention initiatives.
• Identify and maintain an updated network of community resources, social services, and educational workshops to maximize patient health and wellness.
• Exceptional active listening and interpersonal skills with the ability to build trust with diverse populations.
• Strong collaborative skills to seamlessly integrate with clinical care team members in a fast-paced environment.
• Resourcefulness in navigating complex social service systems and overcoming patient barriers to care.
• Basic computer skills and familiarity with tracking systems or Electronic Health Records (EHR) preferred.

Qualifications:

• Education: High school diploma or equivalent required.
• Experience: Prior experience working as a CHW, case management aide, or within a community-based public health or healthcare setting is highly preferred.
• Certification: Formal Community Health Worker (CHW) state certification or credentialing is highly preferred (or willingness to obtain certification upon hire with appropriate training).

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