Community Health Worker

Job Description

Join our team as a Community Health Worker (CHW), where you'll play a vital role in enhancing patient care by addressing social determinants of health and connecting patients with resources to help them manage their health and avoid preventable hospital encounters. Reporting to Case Coordination/Care Coordination, you will provide support to patients in the Emergency Department (ED), ensuring they receive comprehensive care from admission through post-discharge. Your responsibilities will include conducting social needs screenings, enrolling patients in community programs, delivering patient education, coordinating appointments, engaging with patients to reinforce treatment plans, enrollment of patients on the healthcare exchange, and connecting patients to medical homes and other appropriate resources. The CHW will have an assigned patient caseload, conduct regular assessments, and serve as a key collaborator supporting a multi-disciplinary team of physicians, nurses, care managers, social workers, and community stakeholders. 

Essential Functions

• Conduct social needs screenings and intake assessments to identify barriers such as housing, food, transportation, insurance, and medication access.
• Connect individuals to community resources, benefits, and programs; assist with applications and enrollment, including insurance marketplaces.
• Coordinate care needs by communicating member status and risks to clinical teams and facilitating referrals to medical, behavioral health, and social services.
• Support appointment scheduling, follow-up, and transportation coordination.
• Provide timely post-discharge outreach for at-risk individuals to support care continuity.
• Offer patient education, basic counseling, motivational interviewing, goal setting, and advocacy.
• Maintain accurate and timely documentation in required systems such as EPIC and CRISP.
• Build and maintain relationships with community partners and referral sources.
• Support program activities, quality improvement initiatives, and special projects.
• Mentor and provide guidance to junior CHWs.
• Perform other duties as assigned and comply with organizational policies and standards.

Qualifications

Education:

• High School Diploma/GED required
• Associate’s degree preferred

Experience:

• 2+ years of experience in community health, social services, or a related field

Licensure/Certification/Training:

• CPR certification required prior to hire and must be maintained
• Community Health Worker certification required within 1 year of hire and must be maintained
• Valid driver’s license, clean driving record, and reliable vehicle required