Community Health Worker/Mobile Unit

Job Description

The Community Health Worker (CHW) delivers culturally competent services to help patients of all ages navigate and access community services, healthcare resources, and adopt healthy behaviors. The CHW assists with care coordination tasks such as appointments and transportation, patient education, and navigation of physical and behavioral health systems. The CHW facilitates communication between patients, providers, and other members of the care team and supports patients in self-management by evaluating their needs, assisting with care plan development, and working toward patient-centered goals.

The CHW will also support mobile and community-based health initiatives designed to bring healthcare education, prevention, screening, care coordination, and health resources directly to patients in their homes and communities. This may include participation in mobile health events, community outreach activities, remote patient engagement, health screenings, and other programs intended to reduce barriers to care and improve health outcomes.

Responsibilities

Meet patients in the community setting, emergency department, primary care office, hospital, or mobile health site to reinforce and advance patient goals as directed by the Nurse Care Manager.

Participates in mobile health and community outreach activities, including health fairs, screening events, neighborhood outreach, and other community-based initiatives.

Supports the delivery of health education, preventive health information, and basic health screenings within the scope of training and organizational protocols.

Helps identify patients who may benefit from mobile or community-based services and assists with connecting them to appropriate resources.

Makes weekly follow-up calls and regular home visits to patients.

Uses telephone, text messaging, approved digital health platforms, and other remote communication tools to maintain contact with patients and support care plans, as permitted by organizational policies.

Provides outreach and follow-up to patients who have difficulty accessing traditional healthcare settings.

Arranges and coordinates transportation as needed for patients to attend appointments, screenings, mobile health events, and other healthcare services.

Motivates patients and families to meet their health goals and supports ongoing self-management.

Provides culturally sensitive and linguistically appropriate services to patients and families from diverse backgrounds.

Coordinates with the high-risk care team to access resources for identified problems, including homelessness, substance use, food insecurity, transportation barriers, and other social determinants of health after assessment by a licensed social worker/clinician.

Assists patients with organizing medical records, making follow-up appointments, and filling prescriptions.

Reinforces provider instructions and patient education related to preventive care, chronic disease management, medication adherence, and healthy behaviors.

Helps patients understand and appropriately use available healthcare and digital health resources, including patient portals and telehealth services.

Supports remote patient engagement and follow-up activities, including reminding patients about appointments, screenings, preventive services, and care plan activities.

Identifies barriers to care and communicates patient needs, concerns, and changes in condition to the appropriate member of the care team.

Documents patient contacts, outreach activities, referrals, education, and follow-up in the appropriate electronic health record or approved documentation system.

Maintains patient confidentiality and follows all applicable organizational policies, procedures, and regulatory requirements.

Participates in quality improvement initiatives and collects information related to community outreach, patient engagement, and health outcomes as requested.

Performs other duties as assigned within the scope of the position.

Qualifications

Current high school diploma or GED required.

Valid driver’s license required, with a satisfactory driving record and the ability to safely operate and drive the organization’s mobile health unit in accordance with organizational policies and applicable regulations.

Preferred college degree in related areas such as health sciences, healthcare, public health, customer service, administration, or a related field.

Spanish, Portuguese, Khmer, Swahili, and French/Arabic languages required.

Certificate in an Outreach Education program preferred.

Experience working in community health, healthcare outreach, care coordination, public health, social services, or a related setting preferred.

Experience using electronic health records, patient portals, mobile health technology, or telehealth platforms preferred.

Willingness and ability to travel to patient homes, community locations, mobile health sites, healthcare facilities, and other designated locations as required.

Skills, Abilities, and Competencies Required

Organizational skills

Verbal and written communication skills

Interpersonal skills

Customer relations

Cultural competency

Patient engagement and motivational skills

Care coordination

Community outreach

Health education

Ability to establish rapport and build trusting relationships with patients and families

Ability to work effectively as part of an interdisciplinary care team

Ability to use computers and electronic health records

Ability to use approved mobile and digital health technologies

Ability to document accurately and timely

Ability to read and comprehend written instructions

Ability to follow verbal and written instructions

Clerical skills

Problem-solving and resource navigation skills

Ability to work independently in community and home-based settings

Ability to maintain professional boundaries and patient