Community Health Worker; Transition of Care

Responsibilities

• Manages community health by establishing and maintaining trusting relationships with individuals, families, and providers to promote health, recovery, resiliency, and wellness. Advocate and support members and their families by prioritizing their needs and preferences, making sure they receive appropriate care and services promptly.
• Conducts screenings for health risks and access barriers, referring to licensed clinicians as needed. Adjust workflows when necessary to provide optimal care for each situation or individual.
• Uses effective communication techniques, including motivational interviewing, to encourage members to attend regular provider appointments and utilize medical services that support their health. Engage with members and their families to discuss major health concerns and explore solutions to obstacles impacting service delivery, member satisfaction, cost, and community health. These efforts contribute to better care coordination for members overall.
• Delivers comprehensive education, resources, referrals, and connections to health‑related services within the community. Facilitates the introduction of new or underutilized programs and services to community members.
• Provides guidance to community members facing complex health cases in navigating healthcare systems. Responsibilities may include, but are not limited to, conducting home visits, accompanying individuals to appointments, and supporting community events as needed. Exercises sound professional judgment and adheres strictly to scope and licensure boundaries to ensure actions are taken in the best interest of the community member(s).
• Provides culturally appropriate health education and instructions on using existing health and social services, presenting information clearly and effectively.
• Performs all other miscellaneous responsibilities and duties as assigned or directed.

• Associate's degree and three years relevant healthcare/social services experience, or equivalent education/work experience.
• Demonstrated fieldwork experience.
• Excellent communication skills, both written and verbal.
• Basic working knowledge of Microsoft Office applications. Including but not limited to Word, Excel, and Outlook.
• Must have reliable transportation for in-person meetings with members at home or other locations.