Community Health Worker

Community Health Worker

US-OR-Scappoose

The Community Health Worker (CHW) partners with the primary care team to assist patients and their families to improve individual and community health. Responsibilities include culturally appropriate team‑based health promotion and education through direct services provided in OHSU clinics, outreach, and community engagement. The Scappoose Clinic is a rural health center with approximately 12,000 paneled patients and over 35,000 primary care visits per year.

Over 60% of the patient population is insured by either Medicaid or Medicare in a clinic that is centered in Columbia County where community resources are limited. The Community Health Worker demonstrates strong verbal and written communication skills, is self‑directed, and is skilled at developing relationships quickly. The incumbent is efficient and effective in assessing and delivering direct patient care, has an in‑depth knowledge of local community resources, is innovative, thinks creatively, and demonstrates flexibility.

This is a 3‑year limited‑duration position.

• Respond to care team referrals and patient self‑referrals for care coordination, individual and family support, health promotion, and resource system navigation.
• Support individuals and families with complex biopsychosocial needs in coordinating care with external providers and serves as system navigator and point of contact.
• Assumes advocate role on the patient’s behalf to ensure receipt of timely and appropriate services.
• Assists patients in problem solving issues related to health care delivery, financial or social barriers.
• Assists patients in gaining access to community services.
• Collaborates with care teams to meet patient/family and program goals.

• Deliver trauma‑informed and culturally appropriate health education to patients, community members, and healthcare providers. Topics may include system navigation, chronic disease self‑management, nutrition, and practical life skills (e.g., budgeting, cooking).
• Design and implement community‑based interventions and home visits to promote engagement and behavior change.
• Conduct outreach and screening to identify social determinants of health and coordinate responses accordingly.

• Complete timely, accurate documentation in the electronic health record (EHR), including collaborative care plans, progress notes, outreach activity, and billing‑related notes as applicable.
• Ensure services provided are documented to support quality improvement and data tracking.

• Support patients in scheduling, understanding care instructions, arranging transportation, accessing language services, and overcoming other logistical barriers.
• Serve as a patient advocate and liaison between the patient and care team to promote engagement and trust.

• Participate actively in care team huddles, case conferences, staff meetings, and team development opportunities.
• Offer the CHW perspective on patient needs and system improvements.
• Engage with patient advisory groups to strengthen community voice and bridge relational gaps in care.

• Build and maintain effective relationships with community organizations and service providers.
• Facilitate referrals and collaborative efforts to address resource gaps and innovate service delivery.
• Participate in community needs assessments and the development of programs responsive to those needs.
• Collaborate with Patient/Consumer Advisory Councils to improve systems of care.

• High school diploma or equivalent.
• 2 years relevant work experience in a mission‑driven organization with one of those years being experience with underserved populations with complex medical and social needs. Preferred experience in community outreach services providing health information, advocacy, social support, and assistance engaging with the healthcare system.
• Certification as Traditional Healthcare Worker (THW) required. Traditional Health Worker types include Doula, Peer Support Specialist…