Job Description

General Description:

The Wellness Community Health Worker plays a critical role in the health outcomes of patients managing
chronic health conditions, serving as a “linkage” between the patient, health center, and community-based
resources to support patients in addressing social, cultural, environmental, and behavioral factors
affecting their health. The Community Health Worker will work under the direction of and in
collaboration with Wellness leadership to provide care coordination and health education to support
patients in effective management of chronic health conditions, as well as support primary care teams and
specialty clinics to engage patients in chronic disease management and prevention. In alignment with the
agency’s mission to eliminate health disparities through evidence-based, culturally-responsive health
promotion programming, the Community Health Worker will also serve as a liaison to the Wellness
Center, facilitating a variety of group-based educational programs focused on self-management, physical
activity, and nutrition.

Reports to: Wellness Nurse Manager and/or QI & Wellness Project Manager
Supervises N/A
Salary/Status Non-Exempt
Hours: 40 Hours/Week

Note: This position is grant-funded

Minimum Requirements:

 Oral and written fluency in English (fluency in another language a plus, such as Spanish, Arabic, Russian, Vietnamese, Nepali, Somali, or Swahili).
 Associate’s or technical degree/certification in a health, human services, or education field, OR equivalent professional or lived experience.
 Holds Community Health Worker certification, OR willing to obtain training and certification upon hire (offered onsite at no cost).
 Prior training/certification in facilitation of evidence-based wellness programs will be highly prioritized, such as Chronic Disease Self-Management, Diabetes Self Management, Asthma Home Visiting, or other related curricula.
 Ability to independently and effectively balance and prioritize daily tasks, including caseload management, pre-scheduled client visits, walk-in visits/warm handoffs, community outreach, special projects, and occasional trainings, webinars, and meetings.
 Understanding of complex medical, social, cultural, and environmental challenges commonly experienced by individuals and communities who seek community health center services.
 Ability to assist individuals with a compassionate and professional demeanor, and to exercise patience and tolerance with individuals who are confused or frustrated.
 Ability to exercise cultural sensitivity when providing care to patients representing diverse
cultures, ethnicities, religions, sexual orientations, gender identities, socioeconomic statuses, educational backgrounds, worldviews, literacy levels, and languages.
 Excellent interpersonal communication skills and ability to build effective working relationships with diverse client populations, medical staff, interpreters, and community partners.
 Comfortable and willing to facilitate group-based educational activities and to represent agency at public engagements, including health fairs, mobile clinics, radio interviews, press conferences, and community events.
 Ability to draw on knowledge, logic, internet resources, and training materials to problem-solve independently.
 High reliability and commitment to adhere to designated work hours/tasks.
 Ability to respond to Provider and team requests in a timely manner.

 Ability to maintain an organized, clean, and professional workspace.
 Ability to practice discretion and maintain absolute compliance with state, federal, and internal policies when handling confidential client information.
 Ability to navigate and utilize web browsers, Microsoft Office applications, databases, Electronic Medical Record systems, and other digital tools.
 Personal transportation to travel to occasional out of-town trainings, meetings, and outreach engagements.
 Flexibility to conduct outreach engagements on occasional weekends and evenings.
 Ability to work full-time, on-site, and in-person providing direct patient services. Principle Responsibilities and Duties:
 Serve as a direct point of contact for interdisciplinary clinical teams including Primary Care Providers, Nurses, Medical Assistants, Cardiometabolic Team, and Asthma Team to support patients in managing chronic health conditions, including diabetes, prediabetes, hypertension,
dyslipidemia, cardiovascular disease, stroke, and asthma.
 Utilize patient registries to conduct proactive tracking, outreach, and scheduling to engage high- risk patients in primary care and specialty clinics, including Self Monitored Blood Pressure Program, Hypertension Clinic, Asthma Clinic, Spirometry Clinic, Medication Therapy Management Clinic and Diabetes Clinic.
 Provide operational support to designated specialty clinics, including schedule management, internal referral management, and patient reminders.
 Collaborate with Wellness Nurse Manager, QI & Wellness Project Manager, and other Wellness Community Health Workers to satisfy requirements for various grants focused on chronic disease prevention and management, including:
o Attend meetings with grant funders, community partners, and internal committees.
o Maintain documentation of productivity, outreach, trainings, and other objectives as required for program monitoring.
o Be responsive to changes in workflows based on evolving grant needs.
 Provide thorough social needs screenings to assess patient barriers to care, with a goal to address social, cultural, environmental, and behavioral factors affecting their health; provide care coordination by serving as a “linkage” between the patient, health center, and community-based resources.
 Provide informal health education to coach patients in effective management of chronic health conditions and motivate patients to be active participants in their health.
 Serve as a liaison to the Wellness Center, including:
o Process internal referrals to Wellness Center.
o Recruit and enroll patients in Wellness Center programs, including group-based physical activity, nutrition, cooking, and stress management classes.
o Orient patients to Wellness Center equipment, schedules, and guidelines.
o Connect patients with appropriate internal and/or community-based resources for physical activity, nutrition, stress management, and other wellness needs.

 Facilitate group-based educational workshops, including Chronic Disease Self-Management and Diabetes Self-Management; maintain required facilitator certifications.
 Conduct asthma home visits (after completing required training), provide case management, and advocate for families managing asthma to improve housing conditions.
 Conduct community outreach at health fairs, mobile clinics, radio interviews, press conferences, and community events, as needed.
 Utilize existing CHW resources to guide patient care, such as resource databases and established internal workflows.
 Continuously expand knowledge and understanding of community resources and services, public health prevention practices, and evidence-based intervention programs.
 Document activities, care plans, and results in appropriate data collection tools and/or Electronic Medical Record in a clear and concise manner.
 Provide additional wellness support as reasonably assigned.

Working Conditions:
1. This position may require the ability to work long and arduous hours.
2. This position requires the ability to use a computer workstation, viewing a CRT.