Community Health Worker

About Strong Children Wellness

Strong Children Wellness operates a dynamic network of primary care practices seamlessly integrated into community-based organizations that focus on children and families. Our trailblazing healthcare approach holistically addresses medical, behavioral, and social needs under one roof. Our pioneering 'reverse integration' model offers families a tailor-made, multidisciplinary care team dedicated to comprehensive physical, developmental, behavioral, and social care and wellbeing. Discover more about our innovative healthcare solutions at www.strongchildrenwellness.com

As an organization, we prioritize building teams that reflect the diversity of patients we serve and creating a work environment that emphasizes personal wellness, professional development, and team building.

We are seeking a mission-driven Community Health Worker (CHW) to provide patient navigation, care coordination, and care management support for families with unmet social needs across our practice as well as for patients enrolled in our Health Home program, which serves children and young adults with medical and psychosocial complexity..

CHWs are trusted frontline advocates who help families overcome barriers to care. This role includes screening for health related social needs, connecting families to community resources, providing follow-up support, and offering home-based visits for patients with complex psychosocial needs.

This position is ideal for someone who is deeply committed to supporting families affected by poverty, immigration-related challenges, housing instability, food insecurity, and involvement with child welfare systems.

A Typical Day May Include

• Screening patients for unmet social needs and documenting findings in the electronic health record.
• Connecting families to community-based resources (housing, food access, transportation, legal support, etc.).
• Arranging transportation services and coordinating specialty care appointments.
• Providing phone, text-based, and in-person follow-up to address patient concerns.
• Supporting care management for a defined panel of patients in our Health Home program, which can also include home visitation when appropriate.
• Collaborating closely with medical & behavioral health providers, Health Home care managers, and the Program Manager of Social Care services.
• Participating in weekly supervision meetings and case discussions.
• Tracking referrals and ensuring follow-through on care plans.
• Using HIPAA-compliant messaging platforms and project management tools to coordinate care.
  
  

Responsibilities

Patient Navigation & Care Management

• Provide culturally responsive navigation support to families experiencing social or economic hardship.
• Manage a defined panel of patients requiring ongoing care coordination.
• Identify urgent social needs and escalate appropriately to clinicians.
  
  

Documentation & Data Reporting

• Accurately enter screening data, case management notes and billing into referral and case management platforms.
• Track referral outcomes and follow up to ensure needs are addressed.
• Maintain compliance with HIPAA and organizational standards.
  
  

Community Engagement

• Build relationships with local community-based organizations and service providers.
• Serve as a bridge between families and external agencies
• Support outreach efforts and community engagement initiatives when needed
  
  

Requirements

About You:

• You are passionate about serving diverse, marginalized, and immigrant communities.
• You approach families with empathy, cultural humility, and respect.
• You are organized, reliable, and comfortable managing multiple cases at once.
• You are flexible and able to travel for home or community visits as needed.
• You communicate clearly and can work independently while remaining connected to a team.
  
  

What You Bring

• Availability for hybrid full-time work, with at least 24 hours per week on-site.
• Bachelor’s degree required; additional training in community health, public health, or social services preferred.
• At least 6 months of relevant experience in care management, mentoring, community outreach, social services, or a related field.
• Preferred:
• Experience working with vulnerable families and diverse communities.
• Six or more months of relevant experience in care management, mentoring, community health, outreach, or similar fields.
• Nice to have:
• Experience working in healthcare settings or community-based organizations.
• Comfort using electronic health records and care coordination platforms
  

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