Job Description

Employment Type:

Full time

Shift:

Day Shift

Posting Job Description

Job Title: Community Health Worker, Social Care Integration

Employment Type: Full time

Shift: Day

Location: Holy Cross Health Partner Sites in Montgomery and Prince George’s Counties

Position Purpose

Are you passionate about making a meaningful difference in the lives of others and dedicated to improving the health and well-being of your community? If so, you may be the perfect fit for the role of Community Health Worker (CHW), Patient Navigator Social Care Integration.

This vital position bridges clinical care and social care needs by helping patients access essential resources such as food, medication, transportation, and housing. As a CHW, you will play a key role in addressing social drivers of health that impact outcomes, ensuring patients can navigate both the healthcare and social service systems with confidence.

As a trusted advocate, you will provide culturally responsive, trauma-informed support to patients and their families. You will conduct social needs screenings, connect patients to community-based resources, and provide follow-up to ensure successful linkage to services. Working as part of a care team, you will help reduce barriers to care, improve health outcomes, and advance health equity across the communities we serve.

Success in this role includes ensuring patients successfully connect to services, closing referral loops, reducing unmet social needs, and supporting improved engagement in care.

In this role, the CHW will provide patient navigation services to address the health and social needs of patients at primary care practice locations throughout Montgomery and Prince George’s Counties. The CHW will be responsible for screening, referral, coordination, follow-up, and tracking of patients in need of health and/or social services (e.g., food, transportation, housing).

The CHW will document all interactions in the electronic health record (EPIC) and other referral platforms, ensuring accurate tracking of resource connections and outcomes. This role requires strong collaboration with clinical staff, care teams, and community-based organizations to ensure coordinated, patient-centered care.

The CHW will serve as an integral member of the care team, participating in care coordination activities such as team huddles and case reviews, while also building and maintaining strong relationships with community partners.

As a "Community Health Worker" you will:

• Conduct standardized screenings for social drivers of health and identify patient needs
• Connect patients to community resources using referral platforms and community networks
• Provide ongoing follow-up to ensure successful linkage to services and close referral loops
• Deliver services to vulnerable and high-risk patients in clinical, home, and community-based settings
• Build and maintain relationships with community partners (faith organizations, community groups, local leaders, etc.)
• Provide culturally responsive, trauma-informed education and support within scope of practice
• Reinforce health literacy and care plan adherence using appropriate tools and resources
• Document patient interactions, referrals, and outcomes in EPIC and other systems
• Collaborate closely with interdisciplinary care teams, including providers, social workers, and behavioral health staff
• Participate in case reviews and care coordination activities
• Conduct home visits and travel within the service area as needed

Minimum Qualifications:

• Comprehensive knowledge of the local community.

• High school graduate or GED required.

• Certified Community Health Worker, preferred.

• Minimum of two years' community involvement experience (i.e., community health worker, volunteer for community-based organization, outreach worker, community navigator, etc.)

• Ability to effectively present information in one-on-one and small group situations to clients, and other employees of the organization.

• Ability to communicate verbally and in writing and to hear or communicate with target population, medical and social service professionals, colleagues, and peers.

• Ability to inspire and motive others.

• Motivational interviewing skills, preferred.

• Proficient with Microsoft Office applications including Word, PowerPoint and Excel

• Bi-lingual skills (Spanish) to work with patients in their native language are preferred.

• Experienced with or willing to learn EPIC and community resource referral platform

• Knowledgeable about community resources in Montgomery and Prince George’s Counties

• Flexible and available for occasional evenings and weekends as needed for community engagement or patient support

• Knowledgeable about community resources in Montgomery and Prince George’s Counties

• Flexible and available for occasional evenings and weekends as needed for community engagement or patient support

Pay Range: $22.83 - $31.96

Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location.

[FT/PT Benefit eligible Roles]:

**0.5 FTE (20 hours weekly) up to 1.0 FTE (40 hours weekly)

Position Highlights and Benefits:

• Comprehensive benefit packages, including medical, dental, vision, mental health, paid time off, 403B, education assistance and voluntary benefits (pet insurance, accident insurance, hospital indemnity and others) available from the first day of employment. 
• Work/Life balance with flexible schedules. 
• Free onsite parking. 
• Our mission and core values are what drive each member of Trinity Health to support each other, communicate openly and respectfully while embracing a culture that nurtures a healing, safe environment for all.  
• Referral Rewards Program

Position Highlights:

• Work/Life balance with flexible schedules. 
• Free onsite parking. 
• Our mission and core values are what drive each member of Trinity Health to support each other, communicate openly and respectfully while embracing a culture that nurtures a healing, safe environment for all.  
• Referral Rewards Program

Holy Cross Health is a Catholic, not-for-profit health system that serves the two most populous counties in Maryland, Montgomery and Prince George’s, with a commitment to being the most trusted provider of health-care services in the area. Founded in 1963 by the Sisters of the Holy Cross, Holy Cross Health is a member of Trinity Health of Livonia, Michigan. Holy Cross Hospital, in Silver Spring, is one of the largest hospitals in Maryland, and Holy Cross Germantown Hospital is the first hospital in the nation built on a community college campus, enhanced by an educational partnership. The Holy Cross Health Network operates primary-care practices and affordable health centers, and offers a wide range of innovative, community-based health and wellness programs. Specialty care, home care and hospice services round out Holy Cross Health’s high-quality and coordinated continuum of care that aims to improve health and let you live life on your own terms.

Holy Cross Health is an Equal Employment Opportunity (EEO) employer.

Qualified applicants are considered for employment without regard to Minority/Females/disabled/Veteran (M/F/D/V) status.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.