Community Health Worker

The Community Health Worker (CHW) serves as a trusted liaison between Sandhills Medical Foundation and the communities it serves. The CHW partners with patients, families, providers, and community organizations to improve health outcomes by addressing social determinants of health (SDOH), reducing barriers to care, promoting preventive services, and supporting chronic disease management. 

The CHW works closely with providers, nursing staff, behavioral health, patient access, care coordinators, and the Continuous Improvement Department to improve patient engagement, increase quality measure compliance, reduce avoidable utilization, and strengthen continuity of care. 

Essential Duties & Responsibilities 

Patient Engagement & Navigation 

• Build trusting relationships with patients and families. 

• Assist patients with scheduling appointments and follow-up care. 

• Support enrollment in insurance, medication assistance, and financial assistance programs. 

• Assist patients in understanding provider instructions and treatment plans. 

• Improve patient engagement with preventive care services. 

Social Determinants of Health (SDOH) 

• Complete standardized SDOH screenings using approved tools (PRAPARE, AHC HRSN, or organization-approved screening). 

• Identify barriers including: 

• Transportation 

• Food insecurity 

• Housing instability 

• Utility needs 

• Employment 

• Financial hardship 

• Social isolation 

• Connect patients with appropriate community resources. 

• Maintain an updated directory of community partners and available services. 

Population Health & Care Gap Closure 

Support organizational quality initiatives by assisting patients with completing preventive and chronic disease services including: 

• Annual Wellness Visits 

• Breast Cancer Screening 

• Colorectal Cancer Screening 

• Cervical Cancer Screening 

• Diabetic Eye Exams 

• Diabetic Kidney Health 

• A1c monitoring 

• Hypertension follow-up 

• Depression screening 

• Immunizations 

• HIV Screening 

• Hepatitis C Screening 

Care Coordination 

• Participate in interdisciplinary care team meetings. 

• Coordinate referrals with community organizations. 

• Follow up after Emergency Department visits or hospital discharges. 

• Assist patients with transportation coordination. 

• Reinforce care plans established by providers. 

• Support transitions of care. 

Health Education 

Provide culturally appropriate education regarding: 

• Diabetes 

• Hypertension 

• Healthy nutrition 

• Medication adherence 

• Tobacco cessation 

• Preventive screenings 

• Women's health 

• Pediatric wellness 

• Chronic disease self-management 

Community Outreach 

• Participate in community health fairs. 

• Conduct outreach events. 

• Build partnerships with local agencies. 

• Assist with mobile health events. 

• Promote available FQHC services throughout the community. 

Documentation 

• Document all encounters in the EHR. 

• Record SDOH screenings. 

• Track referrals and referral outcomes. 

• Update care plans. 

• Maintain timely and accurate documentation. 

Compliance 

• Maintain HIPAA compliance. 

• Protect patient confidentiality. 

• Complete required annual training. 

• Follow HRSA, PCMH, UDS, and organizational policies.

Qualifications:

Education 

• High School Diploma or GED required 

• Associate's Degree preferred 

Certification 

• Community Health Worker Certification preferred 

• Must obtain certification within 12 months of hire if not already certified 

Experience 

• Experience working with underserved populations preferred 

• Knowledge of community resources 

• Strong interpersonal communication skills 

• Bilingual preferred 

Core Competencies 

• Relationship Building 

• Patient Advocacy 

• Cultural Competency 

• Communication 

• Resource Coordination 

• Problem Solving 

• Organization 

• Documentation 

• Teamwork 

• Empathy