Community Health Worker

WVU Medicine

About The Position

The Community Health Worker serves as a trusted community-based liaison, navigator, and member support resource. The role supports patients and members through in-home, clinic-based, telephonic, and community-based wellness visits; health risk assessments and follow-up; identification of barriers to care; connections to health care and social needs resources; and reinforcement of care plan goals. Working with the interdisciplinary care team, the Community Health Worker supports whole-person care and helps patients and members navigate the health care system, address social drivers of health, engage in preventive and chronic disease care, adhere to medication plans, and manage transitions after hospital or emergency department discharge. The position calls for strong communication, comfort working independently in the community, the ability to build trust with diverse populations, and sound judgment in identifying and escalating concerns. This is a non-exempt position scheduled for 36 hours per week.

Requirements

High school diploma or equivalent.
Valid driver’s license.
Strong communication skills, including effective oral and written communication.
Basic computer skills.
Strong organizational and interpersonal skills for working with the health care team and clients.
Problem-solving and analytical abilities.
Ability to exercise independent discretion and decision-making and manage stress appropriately.
Comfort working independently in community settings and ability to build trust with diverse populations.
Frequent standing, sitting, and walking, or ability to sit for long periods; ability to walk moderate distances indoors and outdoors.
Ability to lift, push, or pull a minimum of 40 pounds.
Corrected visual acuity adequate for distance and near objects; hearing aids are permitted, but the employee must be able to function without lip reading.

Nice To Haves

Completion of a Community Health Worker, Community Healthcare Worker, Community Health Education Resource Person, or similar curriculum within one year of hire.
CPR certification.
Medical Assistant, Certified Nursing Assistant, Patient Care Technician, Health Coach, Peer Support, or other health care/community health-related certification.
Prior experience in a health care, community health, public health, social service, case management, care coordination, patient navigation, or related setting.
Experience working directly with patients, members, families, or community members to address barriers to care.
Experience with electronic health records or other documentation systems.
Experience supporting patients with chronic conditions, preventive care needs, medication adherence, transitions of care, or social drivers of health.
Experience conducting outreach, home visits, community-based visits, or field-based work.

Responsibilities

Conduct in-home, clinic-based, telephonic, and community-based wellness visits with patients and members as assigned.
Complete health risk assessments, social needs screenings, and follow-up to identify barriers involving health care access, food, housing, transportation, medication access, safety, utilities, and other social drivers of health.
Provide support, education, and reinforcement to help patients and members understand and follow individualized care plans.
Support medication adherence by providing reminders, identifying access or understanding barriers, and escalating concerns to the appropriate clinical team member.
Assist with appointment reminders, follow-up care, preventive screenings, immunizations, routine checkups, and appropriate use of the medical home.
Facilitate transitions of care after hospital, emergency department, or skilled nursing facility discharge through outreach, follow-up, appointment coordination, resource connection, and escalation of concerns.
Connect patients and members to appropriate internal and external resources.
Help patients and members access community resources such as food assistance, housing support, transportation, utility assistance, financial assistance programs, and other social services.
Assist with forms, applications, resource referrals, and follow-up steps needed to access potentially eligible programs or benefits.
Serve as a liaison among patients and members, families, community organizations, health care providers, clinics, and social service agencies.
Build supportive relationships that promote engagement, self-management, and active participation in health and wellness goals.
Document encounters, outreach attempts, assessments, identified needs, interventions, referrals, and follow-up in the appropriate electronic system according to departmental expectations.
Escalate safety concerns, unmet social needs, health-status changes, behavioral health concerns, medication concerns, suspected abuse or neglect, and barriers requiring clinical or social work intervention.
Maintain current knowledge of community resources, health care services, payer resources, internal programs, and referral pathways.
Collaborate effectively as part of a team and work independently in community-based settings.