Community Health Worker

Location: Stroud

Job purpose

The Community Health Worker position is a grant funded, exempt level position beginning August 1, 2026-September 30, 2031, who collaborates with local resources to plan and implement health programs that promote community wellness and disease prevention. A Community Health Worker is a trained health advocate who plays a critical role in bridging the gap between communities and health systems who can navigate local resources for the benefit of patients after discharge.

The Community Health Worker plays a key role in strengthening community partnerships and enhancing the hospitals outreach efforts by advancing health equity, improving health outcomes, and reducing avoidable utilization by identifying gaps in healthcare access and working to develop processes which fill those gaps.

Essential functions — include but not limited to Community Engagement to Address Health-Related Social Needs (HRSN).Conduct Health Education and Community Outreach.

Advocacy, Solution Development for Closed-Loop Referrals, and Navigation Between Providers and Community Resources.

Social Support and Informal Counseling.

Care Coordination and Referral Follow-up.

Developing Referral Workflows Within and Outside the Facility.

Assist in Gathering and Reporting HRSN Indicators.

Key Responsibilities:

Educate individuals and communities about how to use health and social service systems.

Build health literacy and cross-cultural communication.

Educate systems about community perspectives and cultural norms utilizing CLAS standards.

Facilitate health promotion and disease prevention education in a manner that matches linguistic and cultural needs of participants or community.

Provide necessary information to understand and prevent disease and to help people manage health conditions (including chronic disease).Participate in care coordination and/or case management.

Make referrals and provide follow-up.

Facilitate transportation services and help address barriers to services.

Document and track individual and population level data.

Inform people and systems about community assets and challenges.

Motivate and encourage people to obtain care and other services.

Support self-management of disease prevention and management of health conditions.

Plan and or facilitate support groups.

Advocate for the needs and perspectives of communities.

Participate in policy development addressing basic needs that impact healthy living.

Work with county-based resources to build community capacity.

Integrate local processes into community advocacy to address gaps in HRSN.Utilize analysis of HRSN reported data to identify interventions strategies and implement community-level solutions to identified gaps.

Participate in community assessments (windshield surveys of community assets and challenges).Follow-up on health and social service encounters with individuals, families, and community groups.

Present at local agencies and community events.

Participate in evaluating CHW services and programs.

Participate in evaluation and research to identify priority SDOH issues.

Gather and report HRSN data.

Share results of findings with local community-based organizations.

Engage stakeholders to act on findings.

Behavioral standards

Supports the mission, vision, and goals of Avem Health Partners and serves as a role model within the organization.

Adheres to the Standards of Behavior:
Respect/Professional Conduct and Attitude, Integrity, Communication, Professional/Personal Development, Commitment to Partners/Community, and Excellence.

Exhibits positive customer service behavior in all work interactions; demonstrates a courteous and respectful attitude to the internal workforce and external customers.

Communicates accurately and appropriately; handles difficult situations in a discreet and professional manner.

Holds self-accountable for professional practice; takes ownership of self and work performed.

Interacts effectively with diverse populations in stressful situations resulting from trauma and illness.

Keeps current with nursing trends, dialysis-specific knowledge, and evidence-based best practices; participates in in-service programs as required.

Assumes responsibility for seeking…