Community Health Worker VBC - Population Health

The Certified Community Health Worker Senior plays a key leadership and operational support role within the CHRISTUS Health Value Based Care Management Team. The Community Health Worker Senior is responsible for leading field-based and telephonic interventions focused on addressing Social Determinants of Health (SDoH), mitigating health inequities, and improving clinical and quality outcomes for attributed populations under value-based contracts.

In addition to providing direct client support, the Community Health Worker Senior serves as a mentor to CHW, supports program planning and process improvement, and acts as a subject matter expert for community-based resource coordination. The role also contributes to performance analytics, partnership development, and health equity initiatives across the region.

• Meets expectations of the applicable OneCHRISTUS
  
  Competencies:
  
  Leader of Self, Leader of Others, or Leader of Leaders.
• Build trusting relationships with Value Based Care patients and their families to identify and address SDoH barriers impacting health and well-being.
• Assist patients in setting personal health goals and navigating care plans.
• Provide hands-on support in accessing healthcare services, social services, transportation, housing, food assistance, and other key resources.
• Encourage patient self-management, including attendance at medical appointments and participation in care planning and education.
• Advocate for patients and communicate patient needs and concerns to the care team and community partners.
• Conduct advanced outreach, need assessments, and care navigation services for high-risk Value Based Care populations.
• Address complex or escalated SDoH cases involving housing instability, food insecurity, mental health, transportation barriers, or multi-system involvement.
• Develop person-centered care plans and reinforce patient self-efficacy through motivational interviewing and health coaching techniques.
• Lead group education sessions or community events that align with population health goals.
• Serve as a mentor and lead preceptor to CHW-level staff, supporting onboarding, training, and field shadowing activities.
• Coach CHWs on effective client engagement strategies, resource navigation, and documentation practices.
• Assist with standardization and development of workflows, toolkits, and quality improvement initiatives in collaboration with Care Management leadership.
• Collaborate with the Value Based Care Leadership to support community health strategies that reduce disparities and improve total cost of care, HEDIS and STARS measures.
• Participate in the design and execution of outreach campaigns, health equity pilots, and process improvement initiatives aligned with value-based contract objectives.
• Work closely with care coordinators, nurse navigators, social workers, and providers to support interdisciplinary care planning.
• Participate in care team huddles and value-based case reviews.
• Document encounters and follow-up actions in the Epic Electronic Health Record (EHR) or other platforms in accordance with Value Based Care documentation standards.
• Accurately document encounters, progress notes, and interventions in Epic EHR or care management platforms, ensuring alignment with compliance and reporting standards.
• Assist with metric development and reporting for grant-funded initiatives, community health assessments, or value-based payment arrangements.
• Conduct internal audits on SDoH team for documentation accuracy.
• Excellent communication, organization, and project management skills.
• Perform other duties as assigned.

• High school diploma or equivalent required.
• Associate or bachelor’s degree in Public Health, Social Work, Health Education, or health related field preferred.
• Must have skills in trauma-informed care, health coaching, and culturally competent engagement.

• Minimum of 3 years of CHW experience, including direct patient navigation or case management for underserved populations.
• Experience working within value-based care, managed care, or VALUE BASED CARE settings is strongly preferred.
• Demonstrated ability to mentor, coach, or lead peers in a professional or community-based setting.
• Strong technical proficiency with care management systems, Microsoft Office, and health information systems (e.g., Epic).
• Deep understanding of SDoH domains and available local/regional resources.

• Current Community Health Worker…