Community Health Worker

Job description

The Community Health Worker (CHW) provides personalized support to patients and families, helping them navigate healthcare and community resources. The CHW works closely with healthcare providers and community partners to address social determinants of health, connect patients to needed resources, and support continuity and transitions of care. Under the GROW Chronic Disease Support and Prevention initiative, the CHW also provides community- and home-based outreach and support for high-risk individuals with diabetes, hypertension, cardiovascular disease, COPD, and other chronic conditions across Benton, White, Carroll, Clinton, Warren, Fountain, Montgomery, and Boone Counties. The role is designed to reduce barriers to care, strengthen chronic disease self-management, improve patient engagement, and connect individuals identified in the field to timely clinical and supportive services.
Essential Duties
• Conduct comprehensive assessments and standardized social needs screenings to identify social determinants of health (SDoH) , barriers to chronic disease management, and needed community or healthcare resources.
• Provide individualized care coordination and guidance through healthcare processes, including appointments, referrals, follow-up care , and connection to appropriate clinical and supportive services.
• Provide approved chronic disease education and self-management support for patients with diabetes, hypertension, cardiovascular disease, COPD, and other chronic conditions, consistent with organizational education pathways and the CHW scope of practice.
• Use motivational interviewing, health-literacy principles, and patient - centered communication to support engagement, self-management goals, and understanding of the established care plan.
• Identify and address barriers such as missed appointments, transportation challenges, food insecurity, housing needs, financial hardship, medication-access or medication-adherence concerns, language or health-literacy barriers, and other unmet social needs.
• Provide transportation assistance and navigation consistent with organizational policy and approved program workflows, including helping patients identify and access appropriate transportation resources.
• Provide appointment support, reminders, scheduling assistance, referral navigation, and follow-up to help patients remain connected to primary, specialty, and other needed care.
• Use closed-loop referral practices by tracking referrals and resource connections, following up on outcomes, and escalating unresolved barriers to the appropriate care team member.
• Engage in proactive outreach to high-risk patients, including individuals with uncontrolled chronic conditions, gaps in care, missed appointments, difficulty managing medications, worsening symptoms, or other barriers identified through approved referral and outreach workflows.
• Conduct approved home visits, community outreach, facility visits, and other field-based activities throughout the assigned service area to improve access to care and support chronic disease management.
• During field encounters, identify patient concerns and barriers, reinforce approved education and the established care plan, and promptly communicate clinical concerns to the designated clinical support team.
• Coordinate closely with the GROW clinical support structure, including the designated Nurse Practitioner, Licensed Practical Nurse, Medical Assistant, providers, nursing leadership, and other care team members to facilitate timely response to needs identified in the field.
• Facilitate connection to in-person or telehealth care when appropriate through established organizational scheduling and clinical workflows.
• Facilitate transitions of care, including post-discharge follow-up from hospitals or emergency departments, and retrieval of discharge summaries or medical records as appropriate.
• Build and maintain working relationships with healthcare organizations, social service agencies, public health partners, and community-based organizations throughout the service area to strengthen referral and resource pathways.
• Participate in community-based chronic disease prevention, health education, and outreach activities designed to reach rural and underserved populations.
• Maintain accurate, timely documentation of patient contacts, outreach attempts, home/community visits, social needs, education, referrals, care coordination activities , follow-up, and outcomes in the designated record or tracking system.
• Support program monitoring and quality improvement by accurately tracking patient engagement, referral completion, chronic disease outcomes, social-needs interventions, and other assigned program measures, including emergency department utilization when included in approved program reporting.
• Participate in quality improvement initiatives, team meetings, interdisciplinary care planning, and huddles to align tasks, priorities, and patient interventions.
• Participate in Patient Centered Medical Home (PCMH) collaboration. Refer to PCMH relevant procedures assigned to this position for more details.
• Assist in collection and assembly of quality improvement information for the purpose of tracking and trending.
• Routine travel throughout the assigned service area may be an essential function of this position, including travel to patient homes, community locations, partner organizations, and outreach activities.
• Perform other duties as assigned.

Training and Certification Requirements
• High school diploma or equivalent required.
• Graduate of an accredited program for Medical Assistant required
• CMA certification preferred.
• Current CPR certification
• At least 1 years’ experience as a Medical Assistant preferred
• Indiana Community Health Worker certification must be obtained/completed within the program-required training period if not already held at hire.
• Complete specialized training in chronic disease self-management, motivational interviewing, care coordination, health literacy, and social determinants of health as required by the GROW initiative and Riggs Community Health Center.
• Minimum of 1-3 years of experience in public health, mental health, case management, healthcare support , community outreach, or a related field preferred.
• Bilingual (English/Spanish) preferred but not required.
• For field-based work, maintain a valid driver's license and meet organizational requirements for operation of a program vehicle.

As Indiana is part of the national Rural Health Transformation Program (RHTP), CMS requires use of a Stevens Amendment disclosure on all materials when mentioning Indiana RHTP funding. The required statement is:
Required Stevens Amendment Disclosure:
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.
Monday-Friday 8:00AM - 5:00PM