Community Health Worker - Population Health

Southwest Healthcare • Albuquerque, NM

12d • Onsite

About The Position

Southwest Care Center is seeking a full-time Population Health focused Community Health Worker in Santa Fe, NM. This role is within the Population Health Department of a Federally Qualified Health Center Look-Alike (FQHC-LAL). The essential duties typically focus on connecting patients to care, addressing barriers, supporting quality initiatives, and improving health outcomes for targeted populations. Southwest Care Center has been providing exceptional healthcare to the communities of Santa Fe and Albuquerque, NM for over 25 years. They are a non-profit, FQHC-LAL providing medical, behavioral health, case management, community outreach, diabetes education, and pharmacy services. They also offer gender equity medicine, syringe exchange, and HIV/HEPC testing and services.

Requirements

• Knowledge of community resources and social service systems.
• Understanding of barriers impacting underserved populations.
• Ability to build trust and rapport with diverse patient populations.
• Strong communication, motivational interviewing, and problem-solving skills.
• Ability to work independently while collaborating within an interdisciplinary team.
• Basic proficiency with EHR systems, Microsoft Office, and population health tools.
• Ability to maintain accurate and timely documentation.
• 2+ years of experience preferred.

Nice To Haves

• NM Certified Community Health Worker preferred
• Athena EMR experience highly desired
• Team collaborator and patient advocate

Responsibilities

• Conduct outreach to patients identified through population health reports, registries, provider referrals, and care management programs.
• Contact patients by phone, text, mail, or in person to facilitate engagement in care.
• Re-engage patients who are overdue for preventive services, chronic disease management visits, immunizations, or follow-up appointments.
• Assist with locating and reconnecting patients who have become lost to care.
• Assist patients in navigating healthcare services and understanding their care plans.
• Coordinate appointments with primary care, behavioral health, dental, specialty care, pharmacy, and community-based services.
• Support transitions of care following emergency department visits, hospitalizations, or specialty referrals.
• Facilitate communication between patients and members of the care team.
• Screen patients for social needs such as food insecurity, housing instability, transportation barriers, utility assistance, and financial hardship.
• Connect patients with community resources and social service agencies.
• Assist patients with completing applications for benefits and support programs when appropriate.
• Follow up on referrals to ensure needs have been addressed.
• Support population health campaigns focused on preventive screenings, immunizations, chronic disease management, and quality measures.
• Assist with outreach efforts related to UDS measures, PCMH initiatives, and value-based care programs.
• Participate in care gap closure activities for targeted patient populations.
• Maintain patient registries and work queues as assigned.
• Provide culturally appropriate health education regarding chronic disease management, preventive care, medication adherence, and healthy lifestyle choices.
• Reinforce provider recommendations and care plan goals.
• Encourage patient self-management and activation.
• Promote health literacy and understanding of available healthcare services.
• Document patient interactions, outreach attempts, referrals, and outcomes in the electronic health record (EHR).
• Maintain accurate records of community resource referrals and follow-up activities.
• Assist with data collection and reporting requirements related to quality improvement initiatives.
• Ensure documentation complies with organizational policies and regulatory requirements.
• Participate in interdisciplinary care team meetings and case reviews.
• Assist with implementing patient-centered care plans developed by licensed clinical staff.
• Conduct follow-up contacts to assess progress toward care plan goals.
• Identify and communicate barriers to successful care plan completion.
• Represent the organization at community events, health fairs, and outreach activities.
• Develop and maintain relationships with community organizations and resource partners.
• Promote available health center services within the community.
• Assist with enrollment and retention efforts for vulnerable populations.
• Participate in departmental quality improvement initiatives.
• Maintain knowledge of FQHC, HRSA, PCMH, and organizational standards.
• Complete required trainings and competency assessments.
• Adhere to patient confidentiality and HIPAA requirements.

Benefits

• Competitive pay
• Great work/life balance with generous time off plans
• CME/Professional development reimbursement with additional time off
• Tuition reimbursement
• Full benefits package including medical, dental, vision, 401k, paid time off, professional development programs, and 340B prescription access with substantial employer contribution

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed