Clinical Community Health Worker

Upperline Health•Chattanooga, TN

9d•Remote

About The Position

The Community Health Worker (CHW) is a frontline member of the Upperline Plus care team, responsible for managing a panel of patients through in-home visits and facilitating virtual visits with a Nurse Practitioner (NP). This role bridges the gap between clinical care and the home environment, ensuring patients in rural and underserved areas receive consistent, coordinated, and accessible health care. The CHW serves as the "eyes and hands" for the NP, gathering information, supporting technology use, and building trusted relationships with patients and their families.

Requirements

High school diploma or equivalent
Community Health Worker certification (or willingness to obtain within 90 days of hire, where state-certified programs exist)
Valid driver's license, reliable vehicle, and willingness to travel daily within a rural service area, including to remote or hard-to-reach locations
Comfort using tablets, apps, and basic telehealth/videoconferencing technology
Demonstrated ability to independently research and identify local, regional, and national resources addressing social determinants of health (SDOH), including resources related to food insecurity, housing, transportation, financial assistance, utilities, healthcare access, and other social needs
Ability to assess a patient's individual circumstances and social needs and determine which resources, programs, or services are most appropriate for their specific situation
Ability to translate complex program requirements and social-service processes into clear, practical, and patient-friendly guidance
Knowledge of mandated reporting requirements and ability to recognize situations involving suspected abuse, neglect, or exploitation, provided by or observed in working with patients
Ability to appropriately document and communicate concerns while maintaining patient confidentiality, professionalism, and adherence to organizational policies and reporting requirements
Strong interpersonal and communication skills; ability to build trust with diverse rural populations.
Ability to collaborate effectively with community partners/agencies and advocate for patients when navigating social service systems
Ability to work independently in the field with minimal direct supervision

Nice To Haves

Prior experience in home health, medical assisting, EMT/paramedic work, or community outreach
Bilingual/multilingual skills relevant to the service area's population
Familiarity with EHR systems and basic clinical documentation
Existing ties to or knowledge of the local rural community

Responsibilities

Conduct regular scheduled home visits to an assigned panel of patients, following a defined visit cadence based on patient acuity and care plan needs
Perform basic health assessments during visits, including vital signs (blood pressure, pulse, temperature, oxygen saturation, weight), medication reconciliation, and home safety/environmental checks
Observe and document changes in patient condition, living situation, SDOH needs/health disparity needs, or caregiver support, and escalate concerns to the clinical care team promptly
Build rapport and trust with patients and families to support engagement in their care plan
Set up and manage telehealth equipment (tablet, camera, connectivity devices) in the patient's home to enable real-time virtual visits with the NP
Act as the NP's "hands" during virtual visits — assisting with physical exam maneuvers as directed (e.g., positioning a stethoscope or otoscope, guiding the camera), and relaying findings
Ensure patients are prepared for virtual visits (appointment reminders, gathering medications/records, addressing questions or anxiety about the technology)
Troubleshoot basic technical issues with telehealth devices and internet connectivity; escalate persistent issues to IT support
Document all visit findings, vital signs, and observations accurately and promptly in the electronic health record (EHR)
Communicate patient status updates, concerns, and care plan progress to the NP and broader care team on a regular basis
Help coordinate follow-up appointments, referrals, transportation, and connections to community resources (food assistance, home health, social services, etc.)
Support medication adherence through education, pill organization assistance, and refill reminders
Provide basic health education on chronic disease management (e.g., diabetes, hypertension, COPD), health literacy support, fall prevention, and healthy lifestyle habits
Educate patients and families on how to use telehealth technology and when/how to reach the care team between visits
Serve as a cultural and community liaison, helping the clinical team understand patients' home environment, social determinants of health, and barriers to care