Community Health Representative; CHR

Position Summary

Serves as a liaison between the Fallon Tribal Health Center and the community by providing health education, patient navigation, care coordination, outreach services, and non-emergency transportation to improve access to care and health outcomes. The CHR supports chronic disease prevention and management, assists patients in accessing medical and community resources, identifies barriers to care, and reinforces care plan adherence during client interactions.

• Maintain the confidentiality, security, and integrity of the patients care and information.
• Provide culturally appropriate health education to individuals, families, and groups on topics including chronic disease prevention and management (e.g., diabetes, hypertension), nutrition, physical activity, medication adherence, and wellness.
• Conduct community outreach and engagement activities, including home visits, community events, and wellness programs to identify health needs and connect individuals to services.
• Assist patients with care coordination and patient navigation, including scheduling appointments, facilitating referrals, supporting discharge planning, and ensuring follow-up care.
• Identify and address social determinants of health (e.g., transportation, housing, food access) and connect clients to appropriate services and programs.
• Support patients in understanding diagnoses, treatment plans, and provider instructions to improve adherence and health outcomes.
• Participate in health promotion and disease prevention programs, screenings, and community-based initiatives.
• Document all client interactions, services provided, referrals, and outcomes in accordance with program requirements and electronic health record (EHR) systems to support billing and reporting.
• Collect and report data to support program goals, grant requirements, and quality improvement initiatives.
• Participate in multidisciplinary care team meetings and collaborate with healthcare providers, nurses, behavioral health, and social services staff.
• Serve as a liaison and patient advocate between clients, families, healthcare providers, and community resources.
• Under appropriate training and supervision, perform basic non-diagnostic health screenings such as blood pressure, weight, and blood glucose monitoring.
• Transports health center clients in a safe and friendly manner and accompany patients to medical appointments as needed.
• Maintain appropriate, accurate travel records (daily and monthly); prepares and submits daily transport record to the CHR Supervisor; and reports all vehicle maintenance needs to the EVS Program.
• Delivers medications from the FTHC Pharmacy to patients as time permits.
• Reports significant observations and events to the CHR Supervisor and/or the attending physician/medical provider.
• Other job-related duties as assigned by the supervisor.

• High School Diploma or GED certification.
• Must possess or obtain Nevada Community Health Worker (CHW) certification within 6 months of hire as a condition of continued employment.
• Must have current CPR and First Aid Certificate, or willing to be certified.
• Must complete required driver safety training, non-emergency medical transport training, and other identified trainings as required.
• Experience in community outreach, healthcare, case management, or related field preferred.

• Ability to work with patients on an individual or group basis.
• Ability to provide culturally appropriate, trauma-informed services.
• Ability to build trust and maintain effective relationships with patients, families, and community members.
• Ability to coordinate services and communicate effectively with healthcare providers and community partners.
• Ability to maintain accurate client records.
• Knowledgeable of Privacy Act and able to maintain confidentiality of records.
• Knowledge of Community Health Worker (CHW) core competencies, including outreach, health education, care coordination, and advocacy.
• Knowledge of chronic disease prevention and management.
• Knowledge of community health, chronic disease prevention, and health education principles preferred.
• Proficiency in…