Community Health Associate - Atlantic Health Morristown Medical Center

Atlantic Health System•Morristown, NJ

About The Position

Community Health Workers build trust with patients, connect them to health and social services, and support them in achieving health goals. They screen for social drivers of health, including food insecurity, housing, and behavioral health needs, and help patients set short-term goals to improve outcomes and access to care. The role requires strong communication, cultural sensitivity, and a passion for community health. The Community Health Associate works with a multidisciplinary Care Coordination team to provide high-quality, outcome-based, patient-centered care. The role supports safe transitions of care, improved patient experience and health outcomes, reduced avoidable cost and utilization, and increased preventative care. The associate helps high-risk patients address social barriers, connect sustainably with healthcare and community supports, and participate in their plans of care. The associate conducts proactive outreach and responds to referrals; meets patients in medical offices, hospitals, homes, or community settings; completes social drivers of health screenings; and works with patients to set health goals. The role includes weekly follow-up calls and home visits, connecting patients with community resources, helping with enrollment in eligible medical, social, and financial programs, and supporting navigation of healthcare services. The associate maintains current knowledge of community resources, collaborates with care teams and community organizations, and documents patient interactions, services, and outcomes. Participation in training, meetings, and departmental processes is also required.

Requirements

High school diploma or GED.
Long-time resident of or familiarity with a community in the role’s service area, with good knowledge of community challenges and resources.
Valid New Jersey driver’s license.

Nice To Haves

Higher educational degree.
Prior experience as an outreach worker or in customer service.
Knowledge of community resources and social service, financial, insurance, and advocacy systems.
Bilingual Spanish.

Responsibilities

Collaborate with a multidisciplinary Care Coordination team to support patient-centered care, safe transitions, improved outcomes, and reduced avoidable costs and utilization.
Help high-risk patients address social barriers, connect with healthcare services and social supports, and engage in their plans of care.
Participate in the AHS CHW training program and onboarding curriculum, follow departmental and organizational policies and standards, and attend assigned meetings, supervisory sessions, and in-service training.
Conduct proactive community outreach to identify people who may benefit from health services and programs, and respond to referrals in a timely manner.
Maintain documentation and performance metrics according to departmental processes and standards, while motivating patients toward self-efficacy and sustainable health and lifestyle changes.
Meet patients in medical offices, hospitals, homes, or community settings; conduct guided interviews and full SDOH screenings; review health needs; and partner with patients to set goals and steps to achieve them.
Use rapport-building, motivational interviewing, effective listening, and cultural sensitivity when working with patients.
Make weekly follow-up calls and home visits to motivate patients and support progress toward health goals.
Connect patients with community resources for social needs such as homelessness, substance abuse, and hunger; assist with enrollment in eligible medical, social, and financial programs and benefits.
Promote preventative healthcare, disease management, and healthy lifestyle education aligned with patient goals.
Help patients navigate healthcare services, organize medical records, schedule follow-up appointments, and access prescriptions.
Maintain knowledge of community agencies and key contacts, assist with patient advocacy and navigation, and help maintain an updated community-resource directory with the Social Services team.
Collaborate with healthcare professionals, social service agencies, and community organizations to help patients make sustainable connections with appropriate providers.
Communicate and collaborate with the interdisciplinary Care Coordination team, AHS/ACO practices, providers, and care team members to address changing psychosocial and medical needs and plans of care.
Document patient interactions, services, and outcomes accurately; prepare reports and documents as requested; and provide patient-specific and caseload updates to a supervising social worker and/or manager.
Perform other tasks as required by the manager, director, or leadership.

Benefits

Medical, dental, vision, and prescription coverage for team members working 22.5 hours per week or above.
Life and AD&D insurance.
Short-term and long-term disability, with options to supplement.
403(b) retirement plan with employer match and additional non-elective contribution.
PTO and paid sick leave.
Tuition assistance, advancement support, and academic advising.
Parental, adoption, and surrogacy leave.
Backup and on-site childcare.
Well-Being Rewards.
Employee Assistance Program (EAP).
Fertility benefits and Healthy Pregnancy Program.
Flexible spending and commuter accounts.
Pet, home, auto, identity theft, and legal insurance.