Community Health Worker / Peer Support / Patient Navigator

Valcore Health • Growing Rural Opportunities for Well-being (GROW)
Region / Program Region 7 • GROW — integrated community, maternal/family, behavioral-health, substance-use,
and chronic-care support.
Region 7 Budget Position: Community Health Worker / Peer Support / Patient Navigator — separate Region 7 personnel line
not identified in the supplied approved budget.
Initiative Allocation: Region 7 initiative assignment and funded FTE to be confirmed. Potential service support is
described below; no percentage allocation is established by this role profile.
Grant Cost Class: Nonclinical service role; grant cost classification and funding source to be confirmed before
charging costs.
Staffing Basis: Headcount, FTE, funding source, start date, and CHW/peer/navigation track to be confirmed; do
not import Region 7 staffing quantities.
Reports To:
Clinical Nurse Coordinator or GROW Program Director; peer services receive qualified peer
supervision when required.
Clinical Accountability: Unlicensed, nonclinical role; works from approved scripts, protocols, consent, and escalation
pathways.
Position Status: Proposed Region 7 role profile; staffing and funding authorization pending confirmation.
Position Purpose:
Build trusted access and continuity for people facing behavioral-health, substance-use, maternal/family, transportation,
technology, and social barriers through outreach, practical navigation, recovery support, and closed-loop follow-up.
Regional setting: Region 7, with primary field deployment in Harrison, Crawford, and Washington counties. Work
occurs in homes, community and partner sites, approved mobile settings, and through telehealth support. The wider
regional partnership covers Brown, Crawford, Harrison, Jackson, Lawrence, Orange, Perry, and Washington counties;
assignments beyond the primary footprint require an approved deployment plan.
Role in the Region-Specific GROW Model:
• Support Region 7 workflows across Mobile Integrated Health; Mobile Healthcare and Screening Services; Improve
Infant and Maternal Health in Region 7; and Navigating Distance Based Health Disparities. Service coordination
across initiatives does not change the position’s approved budget allocation.
• Use coordinated referral, documentation, escalation, and partner workflows with Sloan Paris House Foundation,
hospitals, OB/GYN and pediatric providers, LifeSpring, Centerstone, pharmacy partners, local health
departments/WIC, and other approved Region 7 partners. Clarify Valcore’s clinical-team support and each partner’s
navigation responsibilities.
• Carry approved Region 7 outreach, transportation/resource navigation, appointment completion, patient
education, peer/recovery engagement, and re-engagement workflows. Support home monitoring and telehealth
setup within nonclinical scope; route clinical questions to the assigned clinician.
• Bring participant feedback and access barriers into coalition improvement while preserving privacy and nonclinical
scope.
Shared outcome contribution: engagement and retention in care; completed referrals; maternal, postpartum, and
infant follow-up; chronic-condition follow-up; behavioral-health and substance-use treatment connections; and
reduced unresolved access barriers. Document the role’s own work without treating coalition-wide targets as individual Valcore quotas.

Essential Functions:
• Conduct community-based outreach and engagement using approved messages, consent, safety practices, and
privacy safeguards.
• Help participants understand services, prepare for visits, schedule and complete appointments, use telehealth,
arrange transportation, and navigate benefits and community resources.
• Provide recovery-oriented peer support only when appointed to the peer track and qualified under program
standards; use lived experience purposefully without substituting personal advice for clinical guidance.
• Administer only approved nonclinical screeners, education, and resource-navigation tools; immediately escalate
positive safety, clinical, abuse/neglect, overdose, suicide, pregnancy, or other urgent concerns.
• Track referrals from initiation through confirmed connection, identify barriers, re-engage participants after missed
visits, and communicate unresolved needs to the care team.
• Participate in approved Region 7 community events, mobile-service outreach, and partner meetings; gather
participant feedback and surface service gaps to the coalition.
• Document outreach attempts, encounters, consent, barriers, resources, referral status, appointment completion and escalation in approved systems.

Measurement, Documentation & Grant Accountability:

Maintain source records that permit Valcore and the regional coalition to aggregate, validate, stratify, explain, and
report performance. Use official measure specifications and approved definitions; identify missing data, denominator
limits, duplication risk, and attribution limits rather than estimating unsupported results.
Accountability Area: Reach and Engagement

Required Evidence / Contribution: People contacted, enrolled, engaged, re-engaged, and reasons outreach did not connect.:
Accountability Area: Navigation

RequiredEvidence/Contribution:Appointments scheduled/completed, transportation and telehealth barriers resolved, and follow-up status.

Accountability Area: Closed-loop referrals

Required Evidence / Contribution: Needs/referrals by category, acceptance, completion, unresolved barriers, and escalation.

Accountability Area: Community learning

Required Evidence / Contribution: Events/workshops, education contacts, participant feedback, service gaps, and resulting
workflow action.
• Follow the approved GROW grant agreement, current E.1 budget justification, regional work plan, logic model,
outcome-measure appendix, Valcore policies, and written grant-change controls. Do not materially alter the funded
purpose, FTE allocation, initiative assignment, or deliverable without authorized approval.
• Create timely, accurate, auditable source documentation for services, outreach, referrals, training, partner activity,
time and effort, travel, deliverables, and role-relevant outcomes. Support CMS/State monitoring, quarterly and
annual reporting, audits, corrective actions, and record-retention requirements.
• Protect information under HIPAA, 42 CFR Part 2 when substance-use-disorder records are involved, Indiana
confidentiality law, and Valcore security policies. Use approved systems and the minimum information necessary;
immediately report privacy, security, safety, fraud/waste/abuse, and compliance concerns.
• Maintain grant-cost integrity. Do not supplant unsupported existing salary costs, duplicate reimbursement, or
charge unallowable activity. Keep grant-funded, billable, nonbillable, administrative, and other-program time and
costs appropriately separated as directed.
Professional Scope, Supervision & Decision Boundaries:
• Does not diagnose, triage, prescribe, interpret clinical results, provide psychotherapy, transport patients in a
personal vehicle unless formally authorized, or independently manage emergencies.
• Does not access or disclose more information than needed for the assigned navigation task, including Part 2-
protected information.
• Maintains clear boundaries, avoids dual relationships, and follows peer/CHW ethics and supervision requirements.

Required Qualifications:
• High-school diploma or equivalent; relevant community, navigation, recovery, maternal/family, or human-services
experience.
• Ability to obtain an approved Indiana CHW, peer-recovery, or patient-navigation credential within the
organization's required timeframe for the assigned track.
• Lived experience is required only for a designated peer-support assignment; disclosure is voluntary beyond what is
necessary to establish qualification.
• Valid driver's license, reliable local travel, and ability to work safely in home/community settings and use mobile
documentation technology.
Preferred Qualifications:
• Current CHW or certified peer-recovery credential.
• Knowledge of Region 7 resources, rural barriers, maternal/family supports, and BH/SUD recovery systems.
• Bilingual ability or experience using qualified language services.
Core Competencies:
• Trust and cultural humility
• Practical navigation
• Recovery orientation
• Boundary discipline
• Resource knowledge
• Persistent follow-up
Compliance, Ethics & Participant Rights:
• Provide person-centered, trauma-informed, culturally responsive, accessible, and nondiscriminatory service. Use
qualified language assistance and reasonable accommodations when needed, and follow informed-consent and
patient-rights requirements.
• Complete required screening, credentialing, exclusion checks, training, competency validation, and annual
refreshers. Cooperate with quality-improvement reviews and implement corrective action within assigned
authority.
• Follow current applicable federal and Indiana requirements, including professional licensing and delegation rules,
Indiana telehealth standards, MIH/EMS requirements when applicable, HIPAA, 42 CFR Part 2, emergency and
mandatory-reporting duties, and organizational clinical governance.
• Immediately disclose and manage conflicts of interest. Do not accept impermissible inducements, falsify
documentation, conceal errors, retaliate, or knowingly submit inaccurate program, financial, time, clinical, or
performance information.
Work Environment, Travel & Schedule:
• Frequent regional travel and work in homes, community/partner sites, mobile settings, and telehealth; conditions
and schedules may change with participant and deployment needs.
• May encounter rural connectivity limits, sensitive family circumstances, behavioral-health crises,
pregnancy/postpartum emergencies, weather, and variable physical environments; follows field-safety and
emergency protocols.
• Reasonable accommodation is available. Final physical and schedule requirements will reflect the actual
credentialed duties and deployment model.
Role Flexibility & Change Control:
Controlled flexibility. This grant-funded role is designed to evolve as community needs, CMS/Indiana guidance, approved
performance measures, payer requirements, technology, partner capacity, and implementation evidence change. The
employee may be assigned related duties, locations, populations, workflows, or approved initiative activities that are
reasonably consistent with the role's purpose, qualifications, professional scope, and approved GROW plan. Material
changes to clinical scope, credential requirements, grant initiative, funded FTE, budget classification, or committed
outcomes require documented leadership and grant-authority review before implementation.
Document Control:
Revision date: September 23, 2026; review at least annually and whenever the approved Region 7 budget, work plan,
grant conditions, role scope, law, or operating model changes.
Controlling references: Region 7 approved Attachment B, including Personnel row 21 for the case-manager allocation;
Region 7 grant statement of work, regional work plan, logic model, and project narrative; applicable GROW
requirements; current federal and Indiana law and Valcore policy.
Document purpose: This description defines current essential functions and grant alignment. It does not create a
contract, guarantee funding or employment duration, expand professional scope, or replace current law, privilege,
supervision, or clinical policy.
Acknowledgment:
I acknowledge receipt of this job description and understand that duties must be performed within applicable law, credential, competence, policy, supervision, and approved grant scope.

Employee signature Date
Supervisor signature Date

Steven’s Amendment

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.”

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