Population Health Community Health Worker
Listed on 2026-08-20
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Healthcare
Community Health, Patient/Health Advocate, Health Education & Promotion
The Community Health Worker serves as a trusted community-based liaison, navigator, and member support resource. This role supports patients and members by conducting in-home and community-based wellness visits, completing health risk assessments and follow-up, identifying barriers to care, connecting individuals to appropriate health care and social needs resources, and reinforcing care plan goals.
The Community Health Worker works closely with members of the interdisciplinary care team to support whole-person care. This position helps patients and members navigate the health care system, address social drivers of health, improve engagement in preventive and chronic disease care, support medication adherence, and promote successful transitions of care after hospital or emergency department discharge.
This role requires strong communication skills, comfort working independently in the community, the ability to build trust with diverse populations, and sound judgment in identifying and escalating concerns appropriately.
MINIMUM QUALIFICATIONS
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EDUCATION, CERTIFICATION, AND/OR LICENSURE:
High School diploma or equivalent
Valid Driver’s License.
PREFERRED QUALIFICATIONS
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EDUCATION, CERTIFICATION, AND/OR LICENSURE:
Completion of a Community Health Worker, Community Healthcare Worker, Community Health Education Resource Person, or similar curriculum within one year of hire.
CPR certification.
Medical Assistant, Certified Nursing Assistant, Patient Care Technician, Health Coach, Peer Support, or other health care/community health-related certification.
EXPERIENCE:
Prior experience in a health care, community health, public health, social service, case management, care coordination, patient navigation, or related setting.
Experience working directly with patients, members, families, or community members to address barriers to care.
Experience with electronic health records or other documentation systems.
Experience supporting patients with chronic conditions, preventive care needs, medication adherence, transitions of care, or social drivers of health.
Experience conducting outreach, home visits, community-based visits, or field-based work.
CORE
DUTIES AND RESPONSIBILITIES:
The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned. Conducts in-home, clinic-based, telephonic, and community-based wellness visits with patients/members as assigned.
Completes health risk assessments, social needs screenings, and follow-up activities to identify barriers related to health care access, food, housing, transportation, medication access, safety, utilities, and other social drivers of health.
Provides support, education, and reinforcement to help patients/members understand and follow their individualized care plans.
Supports medication adherence by providing reminders, identifying barriers to medication access or understanding, and escalating concerns to the appropriate clinical team member.
Assists patients/members with appointment reminders, follow-up care needs, preventive screenings, immunizations, routine checkups, and appropriate use of their medical home.
Facilitates transitions of care after hospital, emergency department, or skilled nursing facility discharge by assisting with outreach, follow-up needs, appointment coordination, resource connection, and escalation of concerns.
Connects patients/members to appropriate internal and external resources.
Helps patients/members access community-based resources, including food assistance, housing support, transportation resources, utility assistance, financial assistance programs, and other social service supports.
Assists patients/members with completion of forms, applications, resource referrals, and follow-up steps needed to access programs or benefits for which they may be eligible.
Serves as a trusted liaison between patients/members, families, community organizations, health care providers, clinics, and social service agencies.
Builds positive, supportive relationships with patients/members while promoting engagement, self-management, and active participation in health and wellness goals.
Documents all encounters, outreach attempts, assessments, identified needs, interventions, referrals, and follow-up activities in the appropriate electronic system according to departmental expectations.
Escalates concerns related to safety, unmet social needs, changes in health status, behavioral health concerns, medication concerns, suspected abuse/neglect, or barriers requiring clinical or social work intervention to the appropriate team member.
Maintains current knowledge of community resources, health care services, payer resources, internal programs, and referral pathways.
Works collaboratively and effectively within a team while also demonstrating the ability to work independently in…
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