The Community Health Worker (CHW) supports Hood Memorial Hospital’s quality improvement, population health, and community engagement initiatives with a primary focus on facilitating Chronic Disease Management (CDM), coordinating CDM-related outreach and follow-up, collecting and reviewing CDM data, and serving as the Substance Use Navigator (SUN) for the LA Bridge Program. This position connects patients to care, supports provider-directed care plans, identifies and addresses social drivers of health, coordinates referrals and closed-loop follow-up, and maintains accurate program documentation and reporting, including monthly MCIP data collection for submission.

Essential Duties & Responsibilities

• Chronic Disease Management Facilitation

• Coordinate outreach and follow-up for patients with chronic disease needs, missed or overdue appointments, post-discharge follow-up needs, barriers to care, or noncompliance with chronic disease management expectations.

• Support patients in understanding provider instructions, diagnoses, medications, prevention strategies, and recommended follow-up, as directed by the provider or care team.

• Assist patients with scheduling and attending appointments as needed to improve visit attendance compliance and continuity of care.

• Provide one-on-one or group health education related to chronic disease, prevention, medication adherence, and self-management support.

• Chronic Disease Management Data Collection, Review & Reporting

• Collect, maintain, and review CDM-related data using the EHR, approved tracking tools, and assigned population health platforms.

• Identify patients through EHR SDOH screening data, chronic disease management reports, emergency department utilization patterns, insurance gaps, and other approved data sources.

• Track patient progress, outreach attempts, referrals, follow-up completion, and outcomes related to care plan goals and CDM workflows.

• Participate in quality review, assurance follow-up, interdisciplinary case reviews, huddles, and QI activities to evaluate trends, barriers, opportunities, and interventions.

• Contribute concise, timely data updates for program reporting, leadership review, grant reporting, and performance improvement activities.

• Substance Use Navigator (SUN) / LA Bridge Program

• Serve as the Emergency Department SUN and primary liaison for substance use navigation activities, including screening coordination, brief interventions, MOUD warm handoffs, naloxone education, and referral coordination.

• Coordinate follow-up and closed-loop referrals for patients identified with substance use needs, behavioral health needs, or related social service barriers.

• Maintain SUN-related documentation and tracking requirements in accordance with approved workflows, HIPAA expectations, and program requirements.

• Collect monthly MCIP data elements assigned to the SUN/LA Bridge Program role and prepare data for submission through the designated reporting process.

• Social Drivers of Health, Resource Navigation & Community Linkages

• Conduct standardized SDOH screenings, document findings, and connect patients to appropriate internal and external resources.

• Coordinate referrals and closed-loop follow-up for needs such as food, housing, transportation, Medicaid, Marketplace insurance options, financial assistance, behavioral health, and primary care access.

• Maintain a current community resource/referral list and build relationships with local nonprofits, food banks, housing agencies, behavioral health providers, and social service coalitions.

• Support CHNA review, activities, community health education, community events, and other initiatives that improve population health and access to care.

• Care Coordination, Documentation & Compliance

• Accurately document patient interactions, service encounters, referrals, follow-up activity, and outcomes in the EHR and/or approved tracking systems.

• Apply appropriate Medicaid and Medicare reimbursement codes for eligible services when directed by organizational policy and approved billing workflows.

• Collaborate with providers, medical assistants, nursing, case management, social services, the social worker, the Executive Project Manager, Nursing Educator, and other interdisciplinary team members.

• Maintain patient confidentiality and protect patient information in accordance with HIPAA and hospital policy.

• Identify and report patient safety concerns, neglect, abuse, or other concerns through appropriate escalation pathways.

Required Knowledge, Skills & Abilities

• Understanding of SDOH, chronic disease management workflows, community resource navigation, and patient-centered outreach.

• Strong oral and written communication skills with the ability to provide culturally responsive and trauma-informed engagement.

• Excellent organization, time management, multitasking, documentation, and follow-up skills in a fast-paced clinical environment.

• Ability to work independently while collaborating effectively with clinical, quality, social services, and community partners.

• Computer literacy with proficiency in Windows, Microsoft applications, EHR documentation, and approved tracking/reporting tools.

• Critical-thinking, problem-solving, relationship-building, and patient advocacy skills.

Key Performance Expectations

• Timely completion and documentation of assigned CDM outreach, referrals, follow-up, and outcome tracking.

• Accurate, complete, and timely CDM and SUN data collection, review, and monthly MCIP submission preparation.

• Effective closed-loop referral tracking and escalation when patient needs remain unresolved.

• Consistent participation in interdisciplinary case reviews, huddles, quality review activities, and program improvement efforts.

• Professional communication and collaboration with patients, providers, staff, and community partners.