Be the Bridge Between Healthcare and the Community

As a Community Health Worker, you'll make a meaningful impact by connecting individuals and families to the resources, education, and support they need to achieve better health outcomes. Whether helping patients navigate the healthcare system, overcoming barriers to care, or building trusted relationships within the community, your work will directly improve lives and strengthen the health of the communities Guthrie serves.

Recognized as a Top Healthcare Employer:

Guthrie is consistently recognized for its strong workplace culture and commitment to caregiver well-being, including:

• Best Places to Work 2025 – Modern Healthcare
• America's Greatest Workplaces in Healthcare 2025, 2026 – Newsweek
• America's Best-In-State Employers (PA) 2025 – Forbes
• America's Best Employers for Healthcare Professionals 2025 – Forbes
• America's Best Employers for Women 2025 – Forbes

Schedule & Coverage:

Full-Time, Day Shift

Benefits That Matter:

• Medical, Dental, and Vision coverage starting the first of the month after hire
• PTO starts Day 1
• Voluntary 403(b) Retirement Plan with Employer Match through Fidelity
• Employee Assistance Program providing confidential support for personal and professional well-being
• Shift Differentials and Premiums for evenings, nights, weekends, and float coverage
• Friendly, inclusive work family where you'll feel valued and supported

As the Community Health Worker, you will contribute to improving the health of communities and individuals by screening for Health-Related Social Needs (HRSNs), connecting individuals to services, and providing health education and community resource support.

You will work collaboratively with healthcare systems, social service providers, and community-based organizations to make resources more accessible and improve the quality of service delivery through compassionate, culturally competent support and coordination.

Responsibilities:

Screening and Documentation

• Complete screenings of the patient population for Social Determinants of Health (SDOH).
• Document findings in Epic and other required platforms.

Navigation Services

• Work with Medicaid members to connect them to appropriate services that address their Health-Related Social Needs (HRSNs) and align with their preferences.
• Document interventions in Epic and other required platforms.
• Assist members with scheduling transportation through MAS or other appropriate resources.
• Follow up with members to confirm services were accessed and to determine whether their needs were met.
• Establish and maintain relationships with community agencies, service providers, and key stakeholders to stay informed about available resources and referral pathways.
• Maintain current knowledge of community resources and advocate on behalf of participants and families when working with community service agencies.

Support for Preventive Care

• Assist patients in completing preventive screenings, healthcare visits, immunizations, and other recommended services identified through Health Maintenance or payer quality measure reports.

Cohort Intervention

• Manage an assigned caseload of Medicaid members.
• Provide support for individuals with behavioral health diagnoses and/or individuals who use drugs without utilizing stigmatizing language or practices.
• Communicate compassionately with all individuals seeking services.
• Remove barriers to care caused by limitations, disabilities, resource challenges, or other obstacles.
• Develop Social Care Plans that include:
  • A summary of member needs
  • Eligibility requirements
  • Services to which members are referred
  • Status of referrals
• Update Social Care Plans as needed.
• Monitor and respond to communications received from members.
• Promote appropriate use of healthcare resources by fostering consistent connections with primary care providers.
• Educate patients on appropriate utilization of walk-in clinics and emergency room services.

Attribution Management

• Conduct outreach to attributed patients who are not scheduled for appointments.
• Notify payers when patients are attributed to a non-Guthrie primary care provider.

Qualifications:

• High school diploma or equivalent required.
• Additional education or experience in healthcare or social services preferred.
• Experience working with Medicaid populations and knowledge of Social Determinants of Health (SDOH).
• Strong written and verbal communication skills.
• Ability to communicate compassionately and professionally with individuals seeking assistance.
• Demonstrated empathy and commitment to improving patient outcomes.
• Ability to navigate complex systems of care using critical thinking, patience, and perseverance.
• Strong negotiation skills and the ability to build productive working relationships.
• Excellent planning and time-management skills.
• Adaptable and able to work independently with minimal supervision as well as collaboratively within a team.
• Strong computer skills, including Microsoft Outlook and Microsoft Office applications such as Word, Excel, and PowerPoint.
• Experience participating in or facilitating meetings in person or through virtual platforms such as Microsoft Teams or Zoom.

Preferred Qualifications:

• Community Health Worker certification.
• Proficiency with Epic or similar electronic health record systems.
• Familiarity with the U.S. healthcare system and federally funded healthcare programs.
• Bilingual language skills.

Working Conditions:

• May require travel within the community to meet with patients and community-based organizations.
• Flexibility in working hours may be required to accommodate patient needs.
• Additional responsibilities may be assigned as needed.

Essential Functions:

1. Supports Community Health Worker functions within primary and specialty care practices by:
   • Actively managing a panel of high-risk patients using motivational interviewing, shared decision-making, and goal-setting techniques to increase patient and family engagement.
   • Collaborating with patients, physicians, and other care team members to assess progress toward individual healthcare goals.
   • Providing follow-up support to ensure compliance with recommendations related to community resources, specialist visits, and primary care appointments.
2. Supports Patient-Centered Medical Home (PCMH) initiatives at the practice level through participation in PCMH and Population Health meetings.
3. Supports primary care practices with the use of technology, including Microsoft and Epic software platforms. Responsibilities include:
   • Patient outreach
   • eGuthrie support
   • Health Maintenance activities
   • Care Everywhere utilization
   • Epic Care Link functionality
4. Serves as an active member of the Community Health Worker team through participation in regular team meetings.

Pay Range: $20.38 - $31.81 per hour, based on experience.

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