Build trust through consistent presence and culturally aligned, empathetic communication
Identify and address barriers to care: food insecurity, transportation, housing, and more
Connect patients to care teams and community resources; follow up to ensure needs are met
Document all client interactions, needs, assessments, and outcomes in the EPIC EMR system
Complete SDOH screenings and update care plans in a timely manner
Participate in integrated care huddles and collaborate with clinical teams
Use performance data and feedback to actively refine your approach and improve client outcomes

High school diploma or equivalent
1–3 years in community-based outreach, health education, or related work
Valid driver's license, personal vehicle, and car insurance
Ability to pass background check and pre-employment screening
Flexibility to cover multiple locations within your assigned region
Experience with an EMR system such as Epic (preferred)
Familiarity with Medicaid, D-SNP, waiver programs, and recertification cycles (preferred)
Experience with SDOH screening tools (e.g., Hunger Vital Sign, USDA Household Food Security) or case management platforms (preferred)
Knowledge of HEDIS metrics or risk stratification concepts (preferred)
Strong ties to community organizations: faith institutions, shelters, food banks, or mutual aid networks (preferred)

Community Health Worker

Key skills