Community Health Worker

Job Description

• Identify and engage patients at risk for or are diagnosed with cardiovascular disease (CVD), focusing on moderate-risk individuals.
• Provide culturally responsive education on cardiovascular health, risk reduction, self-management strategies and program benefits.
• Assist patients with appointment scheduling, reminders, and transportation arrangements.
• Conduct proactive outreach to patients who miss visits or are overdue for follow-up to reinforce care plans and reduce missed appointments.
• Build trusting, ongoing relationships with patients, acting as a consistent point of contact to support adherence to care plans and promote self-management and adherence.

• Provide health coaching on lifestyle modifications, including healthy eating, physical activity, stress management, smoking cessation, and medication adherence.
• Support patients in using digital health tools (e.g., home blood pressure monitors, smartphone-enabled ECGs, remote patient monitoring devices).
• Use motivational interviewing and teach-back methods to reinforce provider and care team guidance and instructions and confirm patient understanding.
• Provide ongoing encouragement and support for sustainable lifestyle changes.
• Deliver linguistically and culturally tailored materials to ensure accessibility and patient understanding.

• Conduct Social Determinants of Health (SDOH) screenings using standardized tools (e.g., PRAPARE).
• Document findings in the electronic health record (eClinicalWorks) to inform care planning and referral processes.
• Refer patients to enabling services and community-based resources (e.g., food assistance, housing, transportation, legal aid).
• Collaborate with community-based organizations and agencies to establish seamless connections between patients and SDOH resources.
• Provide follow-up to ensure referred services are accessed, using a bi-directional referral system to support closed-loop referrals and confirm completion of services.

• Actively participate in care coordination huddles with providers, Case Managers, Pharmacists, Nutritionists, and Behavioral Health staff.
• Communicate patient progress, barriers, and social needs with the care team, ensuring coordinated, whole-person care.
• Serve as a bridge between patients, the cardiovascular care team, and community partners.

• Maintain timely, accurate documentation in eClinical
  
  Works, including encounters, referrals, and follow-up activities.
• Assist in chart reviews for quality assurance purposes as requested.
• Assist with data collection and reporting requirements for program evaluation and quality improvement initiatives.
• Participate in QA/PI initiatives, including Plan-Do-Study-Act (PDSA) cycles and staff trainings.
• Support dissemination of program outcomes and lessons learned through patient stories and feedback.
• Perform other duties as assigned to ensure the success of the Center for Justice in Cardiovascular Health.

• To perform successfully, the individual must be able to perform the essential duties satisfactorily. The requirements below are representative of the knowledge, skill and ability required.
• Strong understanding of cultural diversity with a commitment to health equity.
• Bilingual proficiency in English/Spanish strongly preferred.
• Knowledge of cardiovascular health, chronic disease prevention, and social drivers of health preferred.
• Effective communication, problem-solving, and organizational skills.
• Proficiency with Microsoft Office, Outlook, and EHR systems (eClinicalWorks preferred).
• Ability to collaborate effectively with patients, families, providers, and community agencies.
• Decision-making, priority setting, and delegation abilities.
• In-depth knowledge of community services and resources.
• Ability to work independently or as part of a team, meet strict deadlines, and manage group activities.
• Strong interpersonal skills with a customer-focused approach.
• Commitment to maintaining confidentiality.
• Willingness to travel between sites as needed.
• Ability to learn and apply trauma-informed care principles.
• Skilled at interacting with healthcare practitioners, interdisciplinary teams, community agencies, patients, and families with diverse opinions, values, and cultural backgrounds.

High school diploma required;
Bachelor's degree in Public Health, Social Work, or related field…