Community Health Worker - Syracuse Community Health

Forward Leading IPA•Syracuse, NY

7d•$18 - $29•Onsite

About The Position

This position is responsible for establishing trusting relationships with patients while providing support in navigating and accessing resources and engaging patients in goal-driven care. The Community Health Worker systematically identifies, assesses, refers, and monitors high-need individuals to ensure access to essential services while supporting providers and the Care Team through an integrated approach to care management and community outreach. This position is funded through March 2027.

Requirements

Minimum of High School Diploma or GED.
Minimum of 1-3 years' human services experience.
Possess excellent verbal and written communication skills.
Exceptional customer service skills with commitment to helping others.
Ability to quickly adapt and be flexible in approach to job tasks and challenges and maintain emotional control under stress.
Excellent time management skills with exceptional attention to detail and the ability to multi-task and manage multiple priorities with competing deadlines.
Capability to work cooperatively with culturally diverse clients, staff, and community service providers.
Basic computer literacy, including the ability to use email, conduct online research, and create basic documents (MS Office Suite including Excel, Outlook and Word).
NYS motor vehicle license, safe driving record and availability of personal vehicle for work.
Holds self and others responsible and accountable to meet commitments.

Nice To Haves

Associate's degree in human services, Social Work or other related degree preferred.
Equivalent experience in lieu of education may be considered.

Responsibilities

Provide a vital link between local communities and healthcare provider by helping individuals access resources and navigate systems.
Proactively outreach and engage identified individuals in need of services, follow up or social care screening by connecting via phone calls, home visits and/or in-person visits to other settings where patients can be found.
Support deployment of NYS Social Care Network screening and referral process
Engage directly with Medicaid individuals to administer the Health-Related Social Needs Screening Tool to identify needed areas of support.
Facilitate referrals to appropriate community resources and healthcare providers.
Collaborate with the Care Team to ensure timely follow-up and service linkage.
Use designated online referral systems and databases to track and manage client referrals.
Provide care management related to social care services
Accurately document in electronic systems and maintain detailed and organized records in compliance with organizational policies and standards.
Work closely with the Care Team, including care coordinators and other healthcare professionals, to align to a whole person care approach.
Participate in regular team meetings and contribute insights on client progress.
Conduct proactive outreach to attributed Medicaid members with open care gaps in preventive screenings, chronic disease management, and follow-up care.
Collaborate to support performance under value-based contracts by engaging patients who are overdue for services.
Provide education to patients on the importance of routine preventive care and chronic disease monitoring to support improved outcomes and reduced avoidable utilization.
Assist patients with scheduling appointments, arranging transportation, or connecting to community services that reduce barriers to completing recommended care.
Attend regular supervision, staff meetings, trainings and other meetings, as requested.
Other duties as assigned