NWC - Community Health Worker

Overview

Position Title: Full Time/Temporary

Community Health Worker: Practice-Based Date: 09/2022 – Written 01/2026 - Revised

Reports To: Practice Manager

Department: Clinical Operations

Type: Non-Exempt

Position

Purpose:

The Community Health Worker (CHW) helps increase access to health services for vulnerable people who are usually underserved by the health care system, through outreach, education, and peer support. The CHW is responsible for promoting behavior changes, assisting with linkages to appropriate health care services and assisting individuals with self-management of chronic conditions.

• Must be 18 years of age or older.
• High school diploma or GED
• Active CHW Certification (OR Completion of MiCHWA CHW certification program and maintain CEUs)
• Willingness to participate in regular continuing education and professional development
• 2 years of CHW experience
• Must be able to travel with use of a personal vehicle
• Must possess the ability to read and interpret documents
• Must possess the ability to write routine reports and correspondence
• Must possess the ability to speak effectively before individuals and families
• Must possess the ability to interact respectfully with diverse cultural and socio-economic populations

• AS PLANNED BY THE PRIMARY CARE TEAM:
  Conducts outreach and prevention education services, for individuals who have chronic conditions which benefit from care coordination and disease management
• Facilitates Implementation of the patient’s care plan, explaining the plan and answering patient questions, and interpreting health information
• Conducts home visits for follow-up, screening and assessment, health education, and observation of the patient’s living conditions and social needs
• Regularly reports observations to the primary care team to facilitate medical care improvement, health status improvement, and risk reduction
• Assists clients in gaining access to health insurance and other community-based social services
• Promotes patient adherence to the treatment plan through patient and family engagement
• Conducts behavioral health follow up call and connects patients to recommended services
• Documents each patient served and aspects of the encounter in the patient’s electronic medical record
• Establish trusting relationships with patients and their families while providing support and encouragement.
• Work cooperatively with other staff in coordinating patient care and pursuing team-based approaches to care delivery.
• Provide patients with access to school resources and help with IEPs/OHIs as needed
• Schedule patients for follow up appointments after ED/urgent care visits
• Promote patient portal use and increase access to patients for better compliance and communication
• Provides culturally and linguistically appropriate services and health education to clients.
• Maintain a professional disposition while working with a multidisciplinary health care team.
• Coordinate transportation for clients to/from appointments, including accompaniment as needed
• Develop relationships with area social service agencies to build knowledge of the resources available to clients and to provide linkages to these services.
• Participate actively in regular supervisory and team meetings, training sessions, conferences, seminars and independent study.
• Provide ongoing follow-up, motivational interviewing and goal setting with patients/families.
• Follow-up with clients regarding appointments, care plans, and health goals.
• Maintains confidentiality and follows HIPAA standards in safeguarding patient information.

The Practice-Based Community Health Worker (CHW) assists patients in achieving their desired state of wellness. The CHW engages with patients and families on behalf of the primary care/wellness-focused practice. The CHW is skilled in communication, facilitating learning, coaching on health behaviors, developing personal health action plans, and identifying/ addressing barriers to wellness. The CHW is expected to have an understanding of mental illness and addiction, being willing and ready to engage with clients who struggle with these issues.

• Must be able to work a flexible schedule including some evenings and weekends (per agency requirements).
• Able to complete duties under stress, deadlines, and while attending to multiple duties simultaneously.
• Prolonged computer related exposure, as well as sitting and standing at workstations for long periods of time.