Community Health Worker Lead

Brief Description

PRIMARY FUNCTION

The Lead Community Health Worker (Lead CHW) contributes to meeting patients’ comprehensive needs, including social determinants of health (SDOH) and direct medical services. Under the Primary Care Medical Home (PCMH) model, the Lead CHW contributes to patient recruitment, education, navigation, social support, medical follow-up, care coordination, and integration. Chronic disease management and risk factor reduction are often the focus of these efforts, with emphasis on proven chronic disease prevention and control interventions.

In addition to direct community health work responsibilities, this position serves as the central point of accountability for patient flow across clinical care and community-based services. The Lead CHW translates provider care plans into actionable next steps, oversees daily CHW activities, and resolves breakdowns in referrals, care coordination, and system workflows. This role works across clinical teams, CHWs, and health information systems to close care gaps, prioritize work in real time, and ensure follow-through on care plans.

Join the Malama I Ke Ola Health Center Team!

• Team-Based Work Environment
• 90 Day Introductory Period
• Awesome benefits
• Medical, Dental, Vision, life insurance, short & long-term disability, and 403(b) Retirement Plan, FSA, and other voluntary benefits
• Vacation, Holiday and Sick Benefits
  

LEAD COMMUNITY HEALTH WORKER

with Clinical Navigation Liaison Responsibilities

Essential Duties And Functions

• Patient Flow & Care Navigation
  
  

The Lead CHW serves as the primary driver of patient movement across clinical and community-based care pathways:

• Ensure patients move efficiently from identification of need to completed services across clinical and community-based systems.
• Translate provider care plans into clear, actionable tasks for CHWs and care teams.
• Monitor and address breakdowns in care pathways, including delays, missed follow-ups, and incomplete referrals.
• Prioritize patient needs and direct CHW activities in real time to address urgent or high-risk situations.
• Identify High-Needs Patients in collaboration with the Medical Provider; contact all identified High-Needs Patients prior to their next visit to assess whether previous care plan objectives have been completed.
• Coordinate pre-visit planning with RN and Medical Provider; review protocols due for the patient.
• Support navigation of SDOH needs, ensuring patients are connected to appropriate internal and external resources.
• Care Coordination & Community Health Services
  
  

The Lead CHW provides direct patient services at the health center and in the community such as:

• Care coordination to implement and monitor care management plans
• Working with patients, families, caregivers, and community partners
• Resource identification, goal setting, and assistance with self-monitoring
• Culturally and age-appropriate education in multiple languages, including instructional materials, health screens, and clarification of care plans in compliance with clinical protocols
• Patient recruitment: contacting individuals who have not yet established care and informing them about available services
• Assistance with appointment scheduling, including contacting patients with no-show or canceled appointment status and rescheduling.
• Psychosocial support
• Translation and/or interpretation services as qualified
• Transportation coordination
• Financial assistance to access complementary and alternative care options
• Taking vital signs
• Assisting with patient-related paperwork
• Check, maintain, and report inventory supplies to the Program Manager
• Referral Management & Closed-Loop Coordination
• Ensure referrals (internal and external) are completed, tracked, and followed through to resolution.
• Define and maintain standards for closed-loop referrals and care coordination.
• Work with clinical teams to clarify unclear or incomplete referrals and care plans.
• Identify and resolve barriers to patient access.
• CHW Supervision & Team Leadership
  
  

The Lead CHW directly supervises Community Health Workers.

• Oversee daily workflow and task prioritization for CHWs; provide real-time direction on patient engagement strategies and care plan execution.
• Prepare and publish work schedules; approve timecards and time-off requests in compliance with pay policies.
• Recruit, select, train, manage, and motivate CHWs; provide performance feedback during 1:1 sessions and at fiscal year-end.
• Ensure CHW activities align with active clinical care plans and organizational priorities.
• Identify workflow inefficiencies and implement improvements to enhance team effectiveness.
• Support CHW professional development through coaching, feedback, and real-time problem-solving.
• Perform administrative duties as assigned in the Lead capacity.
• Participate in management training sessions and meetings.
• Model Malama I Ke Ola’s core values.
• Community Outreach & Education
• Schedule and coordinate group health education classes.
• Develop and distribute education and communication materials in multiple languages using multimodality approaches.
• Coordinate and implement community outreach events, including staff engagement communication.
• Market community events and CCM programs: create flyers or work with approved vendors; manage event enrollment capacity.
• Participate in relevant meetings for program integration with clinical departments and staff.
• Systems, Data & Reporting
• Identify recurring gaps in patient flow, care coordination, and system processes; recommend and implement workflow improvements.
• Support development of standardized processes for SDOH screening, care navigation, and follow-up.
• Contribute to data tracking and reporting related to care navigation, patient flow metrics, and/or grant activities.
• Compliance & Professional Practice
• Practice within the organization’s Clinical Protocols, Guidelines, and Policies and Procedures.
• Participate in the clinic’s Emergency Preparedness Plan.
• Participate in self-education as required to maintain patient care competencies.
  
  

QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential job function assigned satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education

• High School Diploma or its equivalent.
  
  

Experience

• Experience working in a multi-cultural setting.
• Experience working in a community-based setting; one to two years preferred.
• Experience in a leadership role
  
  

Skills/Competencies

• Written and oral fluency in English required. Other second languages are desirable.
• Knowledge of some medical terminology preferred.
• Basic computer skills.
• Ability to initiate and maintain positive working relationships with staff and other organizations.
• Understand the community served and community connectedness.
• Good communication skills, such as listening well, and using language appropriately.
• Ability and willingness to provide emotional support, encouragement and motivation to patients.
• Ability to communicate in a trauma-informed manner.
• Accurately take and record vital signs.
• Skill in assisting with various treatments and medications, as directed.
  
  

Certifications

• Valid driver’s license.
• Access to an insured vehicle.
• TB clearance within previous 12 months.
• BLS CPR certificate.