Community Health Worker

Position Summary

The Community Health Worker (CHW) is a frontline public health professional who serves

as a trusted liaison between patients, the hospital care team, and community-based

organizations. The CHW screens patients for Health-Related Social Needs (HRSN),

facilitates referrals to community and health resources, supports care coordination, and

conducts community outreach to improve health outcomes and reduce avoidable

utilization.

This position is embedded within the hospital setting and works closely with patients,

clinical, case management, and population health teams to address social drivers of health

and advance health equity.

Key Responsibilities

1. Health-Related Social Needs Screening and Assessment

• Conduct standardized HRSN screenings (e.g., food insecurity, housing

instability, transportation barriers, utility needs, interpersonal safety).

• Conduct nicotine use screening, particularly among adolescent patients 13-17

years of age.

• Identify patients that may be a good fit for chronic disease management

programs (e.g. weight management programs, Diabetes Prevention Programs

(DPP), etc.)

• Utilize hospital-approved screening tools and document findings in the

electronic health record (EHR).

• Utilize Motivational Interviewing best practices to assess patient strengths,

goals, and barriers to accessing care and social services.

2. Referral and Care Coordination

• Provide referrals to internal hospital services and external community-based

organizations.

• Assist patients in navigating and enrolling in community programs and public

benefits (e.g., SNAP, Medicaid, My Life My Quit, etc.)

• Closed loop referrals: follow up with patients to ensure successful connection to

resources and address barriers.

• Collaborate with care managers, social workers, nursing staff, and providers to

support patient-centered care plans.

3. Patient Education & Support

• Provide culturally responsive patient education on disease prevention, chronic

disease management, health system navigation, and tobacco cessation.

• Reinforce discharge plans and medication adherence instructions as

appropriate.

• Support patients in scheduling follow-up appointments and arranging

transportation.

4. Community Outreach & Relationship Building

• Develop and maintain partnerships with community-based organizations, social service

agencies, faith-based groups, and other local stakeholders.

• Participate in community outreach events to promote hospital services and available resources.

• Maintain an up-to-date resource directory tailored to the hospital’s service area.

5. Documentation, Data & Reporting

• Document all patient interactions, screenings, referrals, and follow-ups in the EHR and

designated data systems.

• Track outcomes related to referrals, service utilization, and patient engagement.

• Support quality improvement initiatives related to HRSN screening and social care integration.

• Submit required internal reports in accordance with hospital policies and provide monthly

reports to the Oklahoma Hospital Association as outlined during initial training and program

guidance.

Required Qualifications

• High school diploma or equivalent required; Associate’s or Bachelor’s degree in

public health, social work, or related field preferred.

• Within the first year of work, obtain certification as a Community Health

Worker by completing applicable training or after 1,000 working hours,

whichever comes first.

• Experience working in community health, social services, or healthcare settings

preferred.

• Strong knowledge of local community resources and social service systems.

• Excellent communication, interpersonal, and organizational skills.

• Ability to work effectively with diverse populations and demonstrate cultural

humility.

Preferred Qualifications

• Experience with electronic health record systems.

• Bilingual or multilingual skills reflective of the community served.

• Experience working in rural healthcare settings.

Core Competencies

• Cultural responsiveness and humility

• Patient advocacy

• Trauma-informed approach

• Confidentiality and professionalism

• Team collaboration

• Resource navigation expertise

Work Environment

• Hospital-based clinical setting with some community-based outreach.

• May require travel within the hospital’s service area.

• May include evening or occasional weekend community events.