Community Health Worker

Position Title: Community Health Worker (Transitions Clinic)

Position Purpose: Reporting to the Justice Initiatives Director, the Community Health Worker – Transitions Clinic (CHW-TC) will operate in a supportive role within an interdisciplinary health care team at the DOORWAYS Key Clinic, utilizing an integrated care and treatment model, collaborating with the primary care provider (PCP) and the Behavioral Health Provider to provide health and behavioral interventions that will maximize patient health outcomes. The CHW-TC will provide outreach, case management and navigational services to individuals recently released from incarceration or involved with the criminal legal system with chronic medical, mental health and substance use conditions. The CHW-TC will follow client for up to 12 months – during the most vulnerable months of transition back to the community. The CHW will act as a bridge to help community reentrants stay connected to support. The CHW-TC will work in coordination with the community reentrant and other stakeholders to complete re-entry wellness planning, navigate to care/resources, promote health and wellness, facilitate continuity of care, advocate and coach, and support individuals to set and work towards self-identified goals. The CHW-TC will provide ongoing follow-up and outreach and complete regular data entry.

About Key Clinic Transitions Clinic:

The Key Clinic Transitions Clinic serves individuals returning to the community after incarceration by providing whole-person, patient-centered care that addresses both health and social needs. Our multidisciplinary team works alongside patients to improve access to healthcare, housing, behavioral health services, benefits, employment resources, and other supports critical to successful reentry. Community Health Workers are at the heart of this model, using their lived experience of incarceration, advocacy, and relationship-building skills to help patients achieve their goals and thrive in the community.

The goals of the Key Clinic Transitions Clinic are to:

• Improve access to high-quality healthcare for individuals impacted by the criminal legal system.
• Reduce avoidable emergency department visits and hospitalizations through coordinated care and early intervention.
• Support successful community reintegration by addressing social determinants of health, including housing, employment, transportation, and benefits access.
• Increase patient engagement in primary care, behavioral health, and substance use treatment services.
• Improve overall health, well-being, and quality of life for individuals returning from incarceration.
• Reduce health disparities and advance health equity for justice-involved populations.
• Strengthening connections between healthcare providers, community organizations, and reentry support systems to create a seamless continuum of care.

Required Qualifications:

• History of prior state or federal incarceration
• Two (2) years of verifiable experience providing information, education, intervention and/or referral services to culturally diverse populations and/or community health worker certificate, peer support certificate or CASAC.
• Excellent organization, follow through, and ability to juggle multiple priorities in fast- paced environment with multiple collaborators.
• Willingness to work in various environments, including prison/jail settings, street outreach, home visits at shelters, patient’s residence or homeless encampment.
• Strong analytical, interpersonal, communication and organization skills.
• Demonstrated ability to work independently with minimal supervision while managing competing priorities.
• Proficiency with basic technology such as Microsoft 365/OneDrive, Microsoft Word, Microsoft Excel, and Internet browsing software is required.
• Proficiency with data entry and recording client case notes.
• Strong organizational and administrative skills with attention to detail.
• Occasional evening and weekend work may be required to meet client needs.
• Must have reliable personal transportation with insurance and a valid driver’s license.
• Prior experience working with people aged 18-45, people impacted by the criminal legal system, community-based organizations, uninsured and Medicaid population.

Desired Qualifications:

• Prior experience in community health outreach or similar positions within a health care setting.
• Experience in billing for services and/or documentation of services offered in a clinical settings.
• Recent experience (last 5 years) working as part of a multi-disciplinary team, collaboratively practicing with PCPs, health workers, health educators, and other health professionals.
• Experience with client assessment, treatment planning, conducting interviews/investigations, advising/counseling clients, and participating in health promotion and health education activities.
• Knowledge of State social service agencies and local community resources.
• Knowledge of health education, motivational strategies, and an empathetic manner working with the underserved.
• Experience in a nonprofit, social work, criminal justice setting, or related field.
• Experience working with African Americans, women, LGBTQI and people with substance use and/or mental health needs.

Primary Responsibilities:

• Provides support, empowerment, education and case management services to recently released chronically ill individuals individually and in a group setting.
• Supports the successful day-to-day delivery and implementation of the Transitions Clinic Program Participates/assists as needed in any activities related to the Clinic.
• Provides basic health literacy and information about how to best access and utilize the health and social service system. Educates clients with chronic illness about evidence-based standards of care and self-management of their chronic illness.
• Works together with community reentrants to develop a wellness plan with key goals and objectives to facilitate reentry. Coaches and supports community reentrants to set and accomplish wellness goals.
• Recruits patients by conducting outreach activities in the community, prison, or local jails.
• Facilitates appointments to health and social service organizations. Follows-up on appointments or other instructions from health homes and community providers by call, text or home visit. Works to ensure the reentrant attends and has access to scheduled appointments.
• Communicates with providers about barriers to self-management and access to care. Assists with post-hospitalization or emergency department visit follow up.
• Assists in completing all required forms, agreements, case notes, etc., supplies them to clients when appropriate, and keeps proper documentation organized in an agency approved system.
• Effectively communicates and coordinates with all program-related stakeholders (Key Clinic team, Public Health Coordinator, attorneys, family members, St. Louis County correctional officers, St. Louis County Jail case managers, etc.) to facilitate supports before and after release.
• Assist in gathering and evaluating data concerning the assigned program; may perform incidental clerical duties such as keeping records, answering the telephone and arranging client appointments.
• Complete data entry in a timely manner.
• Maintains confidentiality and uses only the minimum amount of protected health information (PHI) necessary to accomplish job related responsibilities.
• Attend IHN, community, Clinic and partner meetings in a punctual and timely manner
• Attends ongoing training for community health workers.
• Professionally represent IHN and DOORWAYS Key Clinic at a variety of tables and to appropriately share information both with the Director of Justice Initiatives and the Transitions Clinic Program Director.
• Perform other duties as assigned

Competencies:

Incorporates basic competencies into all aspects of the position, including:

• Organizational Commitment: Aligns behavior with the needs, priorities and values of the organization.
• Service Orientation: Has a genuine desire to help others, especially those in need; Derives satisfaction from serving others while remaining attentive to one’s own wellness; Understands people’s needs and overcomes obstacles in serving them.
• Learning Orientation: Values and seeks opportunities to learn; collects and uses information relevant to work-based problems.
• Attitude Toward Change: Adapts to and works effectively with a variety of situations, individuals, groups and systems.
• Personal Effectiveness: Takes initiative to do more than the minimum requirements of the job; Expresses self- confidence in stating opinions and when called upon to make decisions.
• Achievement Motivation: Sets challenging objectives and works to continually improve personal performance.
• Interpersonal and Team Performance: Builds and maintains positive relationships with people on the job; Listens effectively to understand others.
• Values Diversity and Equity: Treats all people with respect; seeks and considers diverse perspectives and ideas; provides a supportive work environment for a multicultural workforce; shows sensitivity to individual differences; treats others fairly without regard to race, sex, color, religion or sexual orientation; engages in personal reflection and development to address unconscious bias, demonstrates no tolerance for micro-aggressions; recognizes differences as opportunities to learn and gain by working together.
• Quality Focus: Minimizes errors and maintains high quality by checking or monitoring data and work in a timely manner, and by developing and maintaining systems for organizing work and information; actively explores ways to improve quality of output.
• Problem-Solving Effectiveness: Uses data and analytical thinking to identify problems and develop solutions.
• Task Accomplishment: Acts resourcefully to ensure that work is accomplished within specified time and quality parameters; Can focus effectively on more than one task or project at a time.
• Proven Track Record and Requisite Skillset: Has a demonstrated track record and/or possesses the requisite skill set required to accomplish the goals and objectives set forth by the IHN; the skills and expertise required include: an understanding of the delivery of local health care, and an understanding of government, regulations, policy and programs.
• Leadership: Exudes confidence in serving as a champion in the formation and implementation of the IHN’s objectives.

Reporting Relationship:

The Community Health Worker – Transitions Clinic reports directly to the Justice Initiatives Director, with oversight from the Key Clinic provider and Transitions Clinic Program Director.

Additional Information:

Position is full-time, 40 hours per week, non-exempt position. Employees will be eligible for full benefits including health, retirement and vacation benefits. Candidates who have been impacted by the criminal legal system are strongly encouraged to apply.

Work Environment:

Regular, daily travel to partner sites and external meetings required within a 30-mile radius. Travel is primarily local during the business day, although some out-of-the-area travel may be expected. Rare overnight travel. The employee is constantly required to talk, hear, and operate a computer and mouse. The employee is frequently required to walk, bend, twist, push, pull, reach above shoulder and use hands to finger, handle, or feel. The employee will occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision and distance vision.

Salary Range:

$21.63 - $24.04 hourly ($45,000 - $50,000 annually) contingent on qualifications and experience

Application Instructions:

Please email resume & reference list to the contact information below.

Subject: Community Health Worker – Transitions Clinic Position

HR@stlouisihn.org

About St. Louis Integrated Health Network:

MISSION OF THE INTEGRATED HEALTH NETWORK

Through partnership and collaboration, the St. Louis Integrated Health Network is a healthcare intermediary building capacity across sectors to advance health equity and improve wellbeing by increasing access to health and social services, with an emphasis on communities that have been historically excluded.

IHN GUIDING PRINCIPLES:

Our guiding principles reflect our most important organizational commitments. They underscore our priorities and inform the decisions, actions and agendas of our leadership and staff. Practiced with fidelity, these principles help to ensure the alignment of our mission and operations. We hold ourselves accountable to these principles and we seek partners who share our commitments to our principles.

Health Equity Patient-Centered Orientation Accountability Outcome-Focused Decision Making Innovation

Job Types: Full-time, Contract

Pay: $45,000.00 - $50,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible schedule
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Parental leave
• Professional development assistance
• Retirement plan
• Vision insurance

Work Location: In person

Salary : $45,000 - $50,000