Serves as a trusted community-based liaison, navigator, and member support resource
Supports patients and members by conducting in-home and community-based wellness visits
Completes health risk assessments and follow-ups
Identifies barriers to care and connects individuals to resources
Reinforces care plan goals
Works closely with interdisciplinary care team
Helps navigate the health care system and improve engagement in preventive and chronic disease care
Supports medication adherence and transitions of care after discharge
Conducts wellness visits and social needs screenings
Documents all encounters and escalates concerns appropriately
Maintains knowledge of community resources and connects patients to them
Works collaboratively and independently in the community.
Requirements
High School diploma or equivalent
Valid Driver’s License
Completion of a Community Health Worker or similar curriculum within one year of hire (preferred)
CPR certification (preferred)
Medical Assistant, Certified Nursing Assistant, Patient Care Technician, Health Coach, Peer Support, or other health care/community health-related certification (preferred)
Prior experience in a health care, community health, public health, social service, case management, care coordination, patient navigation, or related setting
Experience working directly with patients, members, families, or community members to address barriers to care
Experience with electronic health records or other documentation systems
Experience supporting patients with chronic conditions, preventive care needs, medication adherence, transitions of care, or social drivers of health
Experience conducting outreach, home visits, community-based visits, or field-based work.