Community Health Worker VBC - Population Health

Summary:

The Certified Community Health Worker Senior plays a key leadership and operational support role within the CHRISTUS Health Value Based Care Management Team. The Community Health Worker Senior is responsible for leading field-based and telephonic interventions focused on addressing Social Determinants of Health (SDoH), mitigating health inequities, and improving clinical and quality outcomes for attributed populations under value-based contracts.

In addition to providing direct client support, the Community Health Worker Senior serves as a mentor to CHW, supports program planning and process improvement, and acts as a subject matter expert for community-based resource coordination. The role also contributes to performance analytics, partnership development, and health equity initiatives across the region.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Build trusting relationships with Value Based Care patients and their families to identify and address SDoH barriers impacting health and well-being.
• Assist patients in setting personal health goals and navigating care plans.
• Provide hands-on support in accessing healthcare services, social services, transportation, housing, food assistance, and other key resources.
• Encourage patient self-management, including attendance at medical appointments and participation in care planning and education.
• Advocate for patients and communicate patient needs and concerns to the care team and community partners.
• Conduct advanced outreach, need assessments, and care navigation services for high-risk Value Based Care populations.
• Address complex or escalated SDoH cases involving housing instability, food insecurity, mental health, transportation barriers, or multi-system involvement.
• Develop person-centered care plans and reinforce patient self-efficacy through motivational interviewing and health coaching techniques.
• Lead group education sessions or community events that align with population health goals.
• Serve as a mentor and lead preceptor to CHW-level staff, supporting onboarding, training, and field shadowing activities.
• Coach CHWs on effective client engagement strategies, resource navigation, and documentation practices.
• Assist with standardization and development of workflows, toolkits, and quality improvement initiatives in collaboration with Care Management leadership.
• Collaborate with the Value Based Care Leadership to support community health strategies that reduce disparities and improve total cost of care, HEDIS and STARS measures.
• Participate in the design and execution of outreach campaigns, health equity pilots, and process improvement initiatives aligned with value-based contract objectives.
• Work closely with care coordinators, nurse navigators, social workers, and providers to support interdisciplinary care planning.
• Participate in care team huddles and value-based case reviews.
• Document encounters and follow-up actions in the Epic Electronic Health Record (EHR) or other platforms in accordance with Value Based Care documentation standards.
• Accurately document encounters, progress notes, and interventions in Epic EHR or care management platforms, ensuring alignment with compliance and reporting standards.
• Assist with metric development and reporting for grant-funded initiatives, community health assessments, or value-based payment arrangements.
• Conduct internal audits on SDoH team for documentation accuracy.
• Excellent communication, organization, and project management skills.
• Perform other duties as assigned.

Job Requirements:

Education/Skills

• High school diploma or equivalent required.
• Associate or bachelor’s degree in Public Health, Social Work, Health Education, or health related field preferred.
• Must have skills in trauma-informed care, health coaching, and culturally competent engagement.

Experience

• Minimum of 3 years of CHW experience, including direct patient navigation or case management for underserved populations.
• Experience working within value-based care, managed care, or VALUE BASED CARE settings is strongly preferred.
• Demonstrated ability to mentor, coach, or lead peers in a professional or community-based setting.
• Strong technical proficiency with care management systems, Microsoft Office, and health information systems (e.g., Epic).
• Deep understanding of SDoH domains and available local/regional resources.

Licenses, Registrations, or Certifications

• Current Community Health Worker certification required.

In accordance with the CHRISTUS Health License, Certification and Registration Verification Policy, all Associates are required to obtain the required certifications for their respective positions within the designated time frame.

Work Schedule:

5 Days - 8 Hours

Work Type:

Full Time