Community Health Worker Job Fort Cobb Oklahoma USA,Healthcare

Position: Community Health Worker (69948)
Location: Fort Cobb

Community Health Worker

Position Type:
Full Time Job Shift: Day Education Level: High School Travel Percentage:
Up to 50% Category:
Nonprofit - Social Services

Description

Department:
Medical Support Position:
Community Health Work (CHW) Employee Category:
Non-Exempt Reporting Relationship:
Care Management Manager Character Qualities:

Initiative:
Recognizing and doing what needs to be done before I am asked to do it.
Gentleness:
Demonstrates respect, empathy, and concern for patients and families
Flexibility:
Adapts to changing patient and system needs without loss of focus
Responsibility:
Demonstrates accountability, reliability, and follow-through
Integrity:
Acts with honesty, professionalism, and sound judgment

Summary of

Duties and Responsibilities:

The Community Health Worker (CHW) is a frontline, relationship-based Population Health team member and a trusted member of, or one who has a close understanding of, the community served. The CHW serves as a liaison between patients, families, the care team, and the community, working to improve access, health literacy, engagement, and outcomes across the full Variety Care patient experience.

This role integrates the ten core CHW roles and eleven core skill areas defined by the Community Health Worker Core Consensus (C3) Project — the national framework referenced by the Oklahoma Community Health Worker Act and used by the Oklahoma Health Care Authority (OHCA) to define CHW scope of work. The CHW works in close collaboration with clinical teams, care management, behavioral health, and community partners to reduce avoidable emergency department utilization, close gaps in care, and support Variety Care's value-based care and Patient-Centered Medical Home (PCMH) goals.

The CHW maintains structured, longitudinal engagement with a defined panel of high-risk and rising-risk patients while also conducting broader outreach, health education, and capacity-building activities that extend Variety Care's reach into the community.

Outreach & Case-Finding

Conducts proactive outreach and case-finding to identify and connect eligible individuals, families, and community groups to Variety Care services, including through home visits, community events, and partner agencies.

Builds and maintains a current resource inventory of community assets, social services, and referral partners relevant to the assigned patient population.

Prepares and disseminates outreach and health education materials to patients and community members.

Patient Navigation & Care Coordination

Guides patients through healthcare processes including scheduling, referrals, follow-up care, and connection to internal and external resources.

Identifies barriers to care across the patient journey — clinical, social, financial, transportation, and digital access — and works to resolve them.

Tracks referrals and ensures timely closure, escalating unresolved barriers per Population Health workflows.

Supports post-ED and post-hospital transitions by ensuring timely follow-up with primary care, medication access, and continuity of care.

Coordinates CHW activities with clinical staff and other community-based services to support a unified care plan.

Direct Services & Basic Support

Provides basic screenings (e.g., height, weight, blood pressure) and basic supportive services (e.g., first aid, diabetic foot checks) within the defined scope of the role and applicable training.

Assists patients in meeting basic needs by connecting them to direct provision of food, housing, and other essential resources.

Supports telehealth utilization by helping patients understand and access virtual visit options when appropriate.

Longitudinal Engagement & Patient Activation

Maintains ongoing, relationship-based engagement with an assigned panel of high-risk and rising-risk patients.

Utilizes motivational interviewing and coaching techniques to assess readiness for change, support patient goal setting, and reinforce engagement with care plans.

Encourages patient self-management and active participation in care without providing clinical counseling or case management.

Plans or co-leads patient support groups, classes, and community presentations on…