Community Health Worker

Responsibilities

• Build trust through consistent presence and culturally aligned, empathetic communication
• Identify and address barriers to care: food insecurity, transportation, housing, and more
• Connect patients to care teams and community resources; follow up to ensure needs are met
• Document all client interactions, needs, assessments, and outcomes in the EPIC EMR system
• Complete SDOH screenings and update care plans in a timely manner
• Participate in integrated care huddles and collaborate with clinical teams
• Use performance data and feedback to actively refine your approach and improve client outcomes

• High school diploma or equivalent
• 1–3 years in community-based outreach, health education, or related work
• Valid driver's license, personal vehicle, and car insurance
• Ability to pass background check and pre-employment screening
• Flexibility to cover multiple locations within your assigned region
• Experience with an EMR system such as Epic (preferred)
• Familiarity with Medicaid, D-SNP, waiver programs, and recertification cycles (preferred)
• Experience with SDOH screening tools (e.g., Hunger Vital Sign, USDA Household Food Security) or case management platforms (preferred)
• Knowledge of HEDIS metrics or risk stratification concepts (preferred)
• Strong ties to community organizations: faith institutions, shelters, food banks, or mutual aid networks (preferred)