Job Description

Overview

In partnership with patients, their families (as defined by the patient), and multidisciplinary teams, the Community Health Worker– Pediatrics and Obstetrics (CHW) delivers patient-centered care coordination for individuals requiring specialized services. The CHW collaborates closely with patients, parents/guardians, caregivers, healthcare providers, educational systems, and interdisciplinary teams to ensure comprehensive, integrated, and compassionate care.

Responsibilities

Essential Functions:

• Interacts with patients via telehealth and in-person clinic appointments, community spaces, schools, and other locations per program guidelines.
• Serves as a point of contact for patients enrolling in services.
• Collaborates with patients, parents/guardians, caregivers, medical providers, school systems, and interdisciplinary health care teams on patient-centered care.
• Acts as a patient and family advocate to ensure that services are delivered to meet the needs of patients and families, as well as appropriate use of resources.
• Empowers patients and/or their families to be engaged and active participants in their care management.
• Conducts outreach and engagement with patients and families to identify social and community needs impacting health and well-being.
• Assists patients and families in setting achievable goals and support progress through regular follow-up and encouragement.
• Continuously monitors patients’ biopsychosocial needs and provides timely follow-up in alignment with program protocols to ensure continuity of care and support.
• Coordinates transitions between sites and providers of care.
• Coordinates and streamlines patient referrals to appropriate community-based services, ensuring timely access to resources that support health, wellness, and social needs.
• Delivers direct CHW care in alignment with program protocols in accordance with established standards of practice.
• Accurately completes all documentation related to direct and indirect patient care in a timely manner, ensuring that medical records are up-to-date, thorough, and compliant with organizational standards.
• Plays an active role in daily unit-based patient care huddles and periodic clinic-wide informational meetings, patient conferences, and planning sessions. These engagements support quality assurance initiatives, care coordination, and continuous improvement in patient services.
• Participates in ongoing professional development through seminars and educational sessions, ensuring compliance with all certification requirements while staying current with best practices in the field.
• Participates in the implementation and evaluation of quality improvement strategies to ensure compliance with evidence-based guidelines and standards, while identifying opportunities to enhance patient outcomes and care delivery.
• Ensures all tasks provided and associated with patient care, patient administrative processes, and related duties comply with all regulatory and accreditation standards including The Joint Commission and CommUnityCare
• Policies and Procedures.
• Cultivates and sustains positive working relationships and strategic partnerships with colleagues across departments—including leaders, support staff, providers, and other personnel. Communicates effectively with all members of the care team to deliver patient-centered, coordinated care.
• Engages respectfully and collaboratively with patients and their families, utilizing a trauma-informed care approach to foster trust and build positive, supportive relationships.
• Participates in community events and maintains partnerships to promote awareness of available health and social services, as assigned by supervisor.
• Performs any other duties as needed to drive the vision, fulfill the mission, and abide by the values of this organization.

Knowledge, Skills and Abilities:

• Strong problem-solving abilities to effectively support both patients and staff in dynamic care environments.
• Exceptional attention to detail and accuracy in documentation, patient care, and task execution.
• Excellent communication skills, both verbal and written, to ensure clear, compassionate, and effective interactions.
• Expertise in delivering high-quality CHW services and support, aligned with professional standards and ethical guidelines.
• Demonstrated ability to manage multiple CHW responsibilities simultaneously, maintaining efficiency and quality.
• Experience in direct client engagement, including advocacy, and coordination of community resources.
• Competent with healthcare technologies and systems, such as electronic medical records (EMR), patient documentation platforms, and standard office software (e.g., spreadsheets, word processing).

Qualifications

Minimum Education:

• High School Diploma or equivalent (higher degree accepted)

Minimum Experience:

• 3 years of experience working within a community health setting in a health care role or a community based human service agency as a Community Health Worker (CHW), health educator, community outreach worker, or community organizer.

Required Licenses and Certifications:

• CHW Certified Community Health Worker (CHW) in Texas Upon Hire
• CPW Certification Case Management for Children and Pregnant Women certification through Texas Health and Human Services Within 30 Days
• Valid TX Driver's License Upon Hire