Community Health Worker – Field

• Conduct telephonic, virtual, and face-to-face outreach and engagement with assigned members
• Maintain an active caseload of approximately up to 30 members
• Complete required screenings and assessments within required time frames
• Develop and implement individualized action plans with members and interdisciplinary care teams
• Provide education and support related to Type 2 diabetes management, medication adherence, nutrition, physical activity, and lifestyle behaviors
• Identify and address gaps in care and support preventive and follow-up services
• Connect members to community-based resources addressing social determinants of health, including food, housing, and transportation
• Ensure closed-loop referral follow-up
• Assist members in navigating healthcare services, including scheduling and attending primary and specialty care appointments
• Participate in interdisciplinary team meetings and case rounds
• Document member interactions, outreach attempts, and interventions in designated systems
• Support member engagement in pilot initiatives, education programs, community events, and resource utilization
• Promote positive member relationships and culturally competent care aligned with community needs
• Serve as a liaison between members, care management teams, providers, and community resources
• Support the CHW Pilot addressing health disparities, improving outcomes, and reducing avoidable utilization among Medicaid members with Type 2 diabetes

• Experience working in community health, social services, care management, or related field
• Experience engaging with underserved or high-risk populations
• Strong communication, interpersonal, and engagement skills
• Ability to build trust and maintain relationships with diverse populations
• Knowledge of community resources and SDoH-related services
• Ability to manage a caseload and document activities accurately
• Must live in Essex County or nearby
• Community Health Worker (CHW) Certification from the NJ Department of Health, or must obtain within 12 months of employment date
• High school diploma or equivalent required
• Associate’s or Bachelor’s degree in Public Health, Social Work, or related field preferred
• Lived experience or prior work supporting individuals with Type 2 diabetes or chronic conditions preferred
• Experience working within Medicaid or managed care environments preferred
• Bilingual or multilingual skills aligned with community served preferred
• Familiarity with care management systems and electronic health records preferred
• Knowledge of motivational interviewing, cultural competency, and trauma-informed care practices preferred

Demonstrates expertise in community health engagement, care management, and support for individuals with Type 2 diabetes, while effectively navigating healthcare services and community resources. Strong ability to build relationships with diverse populations and address social determinants of health.

• Community Health Worker Certification
• Experience with Underserved Populations
• Knowledge of Social Determinants of Health
• Experience in Care Management
• Bilingual or Multilingual Skills

• Screening and Assessment
• Individualized Action Plans
• Documentation in Care Management Systems
• Motivational Interviewing
• Cultural Competency
• Trauma-Informed Care Practices

• Strong Communication Skills
• Interpersonal Skills
• Engagement Skills
• Relationship Building

• Community Health Worker Certification

• Community Health
• Social Services
• Medicaid
• Chronic Conditions
• Type 2 Diabetes Management

• Electronic Health Records
• Care Management Systems