NATURE OF POSITION

The Community Health Worker (CHW) is responsible for improving access to comprehensive primary care, facilitating care coordination, strengthening community partnerships, and addressing social determinants of health that impact patient outcomes—consistent with the mission of a Federally Qualified Health Center (FQHC) to serve all patients regardless of ability to pay.

This role serves as a liaison between the FQHC care team and the rural community, facilitating access to services, improving quality and efficiency of service delivery, and maximizing partnerships with public agencies, nonprofits, and faith-based organizations. The CHW serves as a bridge between the FQHC and rural community members by providing culturally responsive outreach, care navigation, health education, and resource coordination to reduce health disparities and improve outcomes in Medically Underserved Areas (MUAs).

The CHW will build individual and community capacity by increasing health knowledge and self-sufficiency through outreach, community education, social support, and advocacy—directly supporting the FQHC's HRSA-required community health improvement and enabling services goals.

ROLE DEFINITION

The CHW supports the FQHC and the community by improving patient engagement, expanding access to primary and preventive care, and addressing non-medical barriers that contribute to poor health outcomes and increased healthcare utilization. The CHW plays a critical role in identifying social determinants of health that affect treatment adherence, supporting the FQHC's value-based care and population health objectives, and contributing to Uniform Data System (UDS) reporting requirements.

This will be facilitated through:

·         Community engagement and outreach within the FQHC's service area and designated MUA/MUP

·         Health education and coaching aligned with FQHC clinical priorities

·         Resource navigation, enabling services, and referral coordination

·         Patient advocacy and empowerment

·         Care transition support for high-risk and high utilization patients

·         Data collection and reporting for HRSA/UDS population health initiatives

 QUALIFICATION

·         High school diploma or GED required.

·         Valid driver's license and reliable transportation required.

·         Ability to communicate effectively with diverse, underserved populations.

·         Strong organizational skills for health tracking, data management, scheduling, and community coordination.

·         Ability to work independently in community-based settings within the FQHC's service area.

·         CPR/First Aid certification (or willingness to obtain).

PREFERRED QUALIFICATIONS

•         College education in Social Work, Nursing, or Public Health.

•         Community Health Worker (CHW) certification.

•         Experience with rural populations, community-based outreach, or federally qualified health center settings.

•         Familiarity with HRSA requirements, UDS reporting, enabling services, or FQHC sliding-fee scale programs.

•         Bilingual or multilingual skills reflective of the community served.

CORE COMPETENCIES

•         Strong interpersonal and communication skills

•         Knowledge of rural health challenges, SDOH, and working with vulnerable populations

•         Ability to build trust with diverse and underserved communities.

•         Strong organizational and problem-solving skills

•         Data tracking and reporting in support of UDS and population health goals

•         Basic computer proficiency and EHR data entry

•         Support of FQHC population health initiatives, value-based care models, and enabling services

•          Ability to collaborate with FQHC care teams and CHW networks across Oklahoma

SALARY GRADE AND CLASSIFICATION:   EII- Non-Exempt

 RESPONSIBLE TO:    Director of Nursing

Travel Requirements: Minimum 30% local travel within rural service area/medically underserved area. May require travel outside of county; assess as needed.

RESPONSIBILITIES:

        Community Outreach & Relationship Building

•         Conduct proactive outreach within the FQHC's rural service area and designated Medically Underserved Areas (MUAs) to identify patients with unmet health and social needs.

•         Build trusting relationships with patients, families, and community organizations, particularly among populations facing barriers to primary care access.

•         Support FQHC-sponsored community events, health screenings, and health promotion initiatives, including outreach to uninsured and underserved community members.

Care Coordination & Navigation

•         Assist patients in accessing FQHC primary care, behavioral health integration, dental, pharmacy, and enabling services.

•         Help patients navigate the FQHC care model, sliding-fee scale program, and applicable public benefit programs (e.g., Medicaid/SoonerCare, CHIP, SNAP).

•         Identify and address barriers such as transportation, financial limitations, health literacy, or access challenges through problem-solving and connection to enabling services.

Health Education & Coaching

•         Provide culturally responsive education on preventive health, chronic disease management, nutrition, and wellness consistent with FQHC clinical guidelines and population health priorities.

•         Utilize motivational interviewing and other evidence-based techniques to support positive behavior change.

•         Reinforce FQHC provider recommendations and encourage adherence to treatment plans, follow-up appointments, and preventive care schedules.

Addressing Social Determinants of Health

•         Screen for and address social needs including housing instability, food insecurity, transportation barriers, domestic violence, and access to community resources, using FQHC-approved HRSN tools.

•         Connect patients with appropriate support services and document referrals and outcomes in the FQHC's EHR per HRSA documentation requirements.

Data Collection & Program Support

•         Maintain accurate documentation of outreach activities, enabling services, and patient interactions in the FQHC's EHR and applicable data systems.

•         Support tracking of outcomes related to FQHC population health, UDS reporting, and quality improvement goals.

•         Assist with community health needs assessments (CHNA) and FQHC strategic planning and quality improvement initiatives.

Community Collaboration & Advocacy

•         Develop and maintain partnerships with local agencies, schools, social services, faith-based organizations, and community stakeholders to address community health needs.

•         Advocate for rural and underserved health needs and participate in initiatives that promote health equity within the FQHC's service area.

•         Collaborate with CHWs across the Oklahoma Primary Care Association (OPCA) network as applicable.