Community Health Worker-Population Health

Job Description

Job Description

This Rural Health Transformation Program is supported by the Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $206,927,896.80 with 100 percent funded by CMS/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CMS/HHS, or the U.S. Government.

Principal Function:  The Community Health Worker - Population Health is a trusted community-facing member of the WCCH population health team. Working under the direction of the Population Health Nurse, the CHW builds working relationships with reginal partners and helps patients overcome social determinants of health and other barriers that limit health, wellness, and prosperity. The CHW meets people in clinic and community settings, provides culturally responsive outreach and navigation, connects patients through warm handoffs to healthcare and community resources, follows those connections through completion, and brings community knowledge back to the clinical team. The CHW does not provide independent clinical advice; clinical needs are coordinated with the Case Manager, Population Health Nurse, or provider.

Essential Duties and Responsibilities:  Duties include, but not limited to:

1. 1. Build and maintain working relationship with regional partners, including hospitals, health departments, behavioral health and substance-use organizations, Area Agencies on Aging, transportation providers, food and nutrition programs, housing and utility resources, schools, employers, and workforce programs, faith communities, and other community-based organizations.
2. 2. Participate in regional and community partner meetings, resource mapping, referral-pathway development, outreach planning, and maintenance of an accurate directory of available services, eligibility requirements, contacts, and access processes.
3. 3. Conduct culturally responsive outreach and engagement in clinics, homes when authorized, community events, mobile settings, and trusted community locations to reach people who are disconnected from traditional care.
4. 4. Administer approved social determinants of health and practical-barrier screenings within CHW training and scope; identify patient priorities, strengths, and barriers without independently performing clinical assessment.
5. 5. Help patients address barriers involving transportation, food, housing, utilities, insurance, medication access, finances, digital connectivity, language, health literacy, childcare or caregiving, disability, education, employment, legal needs, and other conditions affecting health, wellness, and prosperity.
6. 6. Support patients in setting person-centered nonclinical goals, understanding available choices, building self-advocacy skills, and connecting day-to-day needs with their broader goals for health, wellness, stability, and prosperity.
7. 7. Provide warm handoffs to healthcare and community partners, assist with referral steps, and follow each connection through completion, documented patient choice, or another documented disposition.
8. 8. Assist patients with appointments, reminders, forms, benefits, or insurance navigation, transportation arrangements, telehealth access, digital literacy, and other practical steps needed to complete care and use community resources.
9. 9. Provide education about available healthcare preventive, wellness, and community services; reinforce care-team instructions using approved materials without providing independent clinical advice.
10. 10. Support nonclinical RPM access through device delivery or pickup coordination basic setup and digital-literacy assistance, connectivity troubleshooting, and adherence outreach; promptly report clinical questions, readings, symptoms, or concerns to the Case Manager, Population Health Nurse, or provider without interpreting clinical data.
11. 11. Collaborate closely with the Case Manager, Population Health Nurse, providers, pharmacy, transportation, Street Medicine, and other staff; share referral and barrier status, bring forward community feedback, and promptly escalate clinical, safety, abuse, neglect, or crisis concerns according to protocol.
12. 12. Maintain accurate, timely, and confidential documentation of outreach, partner contacts, SDOH screenings, patient goals, barriers, interventions, referrals, follow-up, geography, outcomes, and required program measures; participate in staff and regional meetings, training, quality improvement, and field-safety procedures.

Supervisory Responsibilities:  This job has no supervisory responsibilities.

Education and/or Experience: High school diploma or GED required. One year of related community outreach, navigation, human-services, public-health, healthcare, or lived/community experience is preferred. Community Health Worker certification is required at hire or must be completed through an approved 40-plus-hour training program within the WCCH-established timeframe.

Hours 8 am - 5 pm Monday-Friday

Paid Vacation - Sick days - Personal Days -- 12 Holidays

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