Community Health Worker

Overview

The Community Health Worker (CHW) serves as a bridge between the healthcare system and the community, supporting both in-clinic and community-based work with a focus on underserved populations. The CHW plays a key role in identifying and reducing social determinants of health, barriers to care, promoting health education, supporting resource navigation, and coordinating services. A key function of this role includes assisting patients participating in the Collaborative Care Model, working alongside behavioral health care managers and clinical teams to provide integrated healthcare.

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.

OHSU Family Medicine at Richmond is designated as a Federally Qualified Health Center (FQHC) and cares for over 16,000 community members as a part of the community safety net.

We are committed to providing an open and equitable recruitment process with the goal of recognizing diverse lived experience that will contribute to the success of the organization and goals of this position. We are deeply committed to a community of excellence, equity, and diversity and welcome applications from candidates who will contribute to the diversification and enrichment of ideas and perspectives.

Diversity, Equity and Inclusion are core values and accountability to these values helps us better serve our diverse community.

Direct Patient Services and Documentation

• Respond to care team referrals and patient self-referrals for care coordination, individual and family support, health promotion, and resource system navigation.
• Supports 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 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.
• Assist with coordination and follow-up for patients participating in the Collaborative Care Model, working closely with care managers and behavioral health consultants.
• Assists patients in gaining access to community services.
• Collaborates with care teams to meet patient/family and program goals

Health Education, Prevention and Outreach

• 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.

Documentation

• 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.

Clinic Access and Engagement

• 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.

Care Team Meetings and Development

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

Community Engagement

• Build and maintain effective relationships with community organizations and service providers.
• Facilitate referrals and collaborative efforts to…