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The Community Health Worker (CHW) is responsible for bridging gaps between patients, the community, and medical systems to remove barriers and improve wellness. CHWs advocate for patients, manage care plans in coordination with medical social workers, and connect patients to resources such as housing, transportation, and food. High levels of flexibility, problem-solving skills, and communication make the role essential in supporting health literacy and access to care.
Job Responsibility:
Establish and maintain strong interpersonal relationships with patients, community organizations, team members, and partners to coordinate patient needs
Manage patient referrals defined by the care team & collaborate with the Medical Social Worker on action plan
Facilitate communication between all identified parties involved in patients’ care as needed (e.g., family members, caregivers, medical providers, community-based organizations)
Form relationships with and build an inventory of local community organizations that may benefit our patients
Connect patients to state and local community resources related to housing, transportation, food, and activities of daily living among other social and physical barriers to health
Assist patients with completion of applications for accessing eligible benefits and resources
Promote goal setting and achievement to improve patients’ quality of life and self efficacy with patients, with goals agreed upon by the care team
Meet with patients in patient-centered and patient-preferred locations (e.g., Oak Street Health center, patient’s home, external medical provider facility, community setting)
Plan to spend about half of their time outside of the center in patient-centered locations, requiring access to reliable transportation
Drive engagement with high-risk individuals such as appointment adherence and post-discharge visits
Complete referrals to organizations and agencies as needed
Deliver culturally appropriate health education
Support care team decision making through participation in interdisciplinary team meetings
Document interactions with patients in electronic medical record in a timely manner while maintaining HIPAA standards and confidentiality
Manage time, set priorities, work independently, and collaborate effectively with an interdisciplinary medical team
Requirements:
Minimum of 1 year of experience in healthcare, community-based, case management, or social service environment
Strong oral and written communication skills
Ability to manage multiple priorities while maintaining a positive attitude
Dedication to serving the community and building meaningful relationships
Access to reliable transportation and ability to travel throughout the community to various locations
US work authorization
Nice to have:
Fluency in language that is commonly spoken in the community when necessary, most often Bilingual English/Spanish
Experience working on multidisciplinary teams with organizations, agencies, patients, and community members
Knowledge of community resources and resource navigation
Community Health Worker certification or Associates or Bachelors in a related field
Experience utilizing electronic medical record systems
A problem-solving orientation and a flexible and positive attitude
What we offer:
Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan
No-cost programs such as wellness screenings, tobacco cessation, weight management programs, confidential counseling, and financial coaching
Paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access
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