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Community-Health Workers (CHWs) provide social support, navigation, and advocacy to high-risk low-income patients within the communities they serve in order to help them reach their health goals. CHWs act as caring neighbors to help patients address the social, medical and community problems that lead to poor health. The goal is to help patients deal with the `real life' issues that keep them from staying healthy, help with the tasks of getting medical care, and work on health goals by doing things like planning healthy meals or finding time to exercise.

This position requires travel throughout Monmouth, Ocean, and Middlesex Counties. Knowledge of community resources is preferred. Individuals must be able to work in hybrid settings.

• Initiate contact with eligible patients telephonically and/or in person.
• Conduct a social needs screening and document in the Electronic Medical Record (Epic).
• Provide telephonic, in-home, or community-based visits to assist patients with their social and health-related needs.
• Conduct weekly follow ups with patients via their preferred method of communication (telephonic, home or in community setting).
• Meet weekly, monthly, and annual patient/member enrollment targets as set by the department.
• Advocate for patients by motivating them to meet their health-related goals, connecting them to resources in the community that can address social determinants of health needs and educating them on how to navigate them.
• Collaborate with care teams and community-based organization stakeholders to address patient needs.
• Assist patients in filling out applications for community-based programs, organizing patient's paperwork and ensuring patients are connected to their medical care team.
• Prepare reports and documents as needed or requested.
• Attend regular team and one on one departmental meetings.
• Able to work effectively in a hybrid model setting (office, hospital/clinical, community and home) as required based on departmental needs.
• Other duties as assigned.

• High School diploma, general equivalency diploma (GED), and/or GED equivalent programs.
• Experience with accessing social service resources available for New Jersey.
• Must be proficient in MS Word/Google Suite and computer data entry.
• Excellent oral and written communication skills.
• Ability to carry out written and oral instructions.
• Ability to receive and address feedback.
• Valid driver's license and reliable transportation.
• Ability to exercise judgment in the application of professional services.
• Comfortable with telephonic outreach, home visits and outreach in the community.

• Prior experience as an outreach worker (or related title) is a plus.
• Excellent time management skills.
• Bilingual/Multilingual with ability to pass language fluency test.