Community Health Worker - Referral Coordination

Hope Family Health•Westmoreland, TN

About The Position

The Community Health Worker (CHW) helps patients access and navigate HOPE Family Health services and community resources. This position is assigned to Referral Coordination, assisting patients with scheduling referrals, coordinating with outside providers, and following up to support access to recommended services. The CHW communicates with patients and care teams, identifies barriers to care, coordinates follow-up, and documents services accurately. Depending on the assignment, the CHW may focus on medical or behavioral health telephone support, language access, referrals, outreach, care coordination, or connecting patients with resources such as food, housing, financial assistance, and transportation. Duties are limited to the CHW’s assigned area, training, credentials, and HOPE policies; individual CHWs are not expected to perform every duty listed. The role primarily functions in a professional office or clinical environment, with occasional travel between HOPE sites. Off-site work is not required, but specific tasks may be completed remotely with prior Team Leader approval and a confidential designated workspace. Occasional extended hours may be required based on organizational needs. The position may involve exposure to health hazards, including body fluids, and occasional lifting or moving of items up to 25 pounds.

Requirements

High school diploma or equivalent required.
Ability to communicate clearly and respectfully with patients, colleagues, and community partners.
Ability to organize competing tasks and use sound judgment about when to escalate concerns.
Ability to use electronic health records and standard office software, or to learn them with training.
Ability to communicate effectively in English, verbally and in writing.
Sufficient vision and hearing to perform duties and communicate by phone and in person.
Specific assignments may require additional language proficiency, interpreter qualifications, professional credentials, or Basic Life Support certification.
Clinical duties require applicable credentials and HOPE authorization.

Nice To Haves

Relevant experience in health care, behavioral health, patient service, community outreach, or resource navigation.
Knowledge of local resources and barriers to care.
Fluency in a second language.

Responsibilities

Build respectful, trusting relationships with patients and families; communicate in a culturally responsive manner and support patient choice and self-advocacy.
Contact patients by telephone, electronic message, or in person as assigned; respond to questions, relay approved information, identify needs, and route clinical concerns promptly to appropriate licensed staff or providers.
Help patients understand appointments, care plans, referrals, tests, and next steps using information approved by the care team; reinforce education and instructions without independently diagnosing, treating, or giving clinical advice.
Identify barriers to care, including transportation, insurance, cost, language, food, housing, and access to services; connect patients with HOPE programs and community resources and follow up on connections as assigned.
Coordinate with medical, behavioral health, pharmacy, and other teams and external partners to support continuity of care and timely follow-up.
Maintain timely, accurate records of contacts, referrals, services, and follow-up in the electronic health record and other approved systems; protect confidential information.
Participate in team meetings, training, quality improvement activities, and updates to resource information and workflows.
For telephone support assignments, manage incoming and outgoing patient communications, route messages, relay provider-directed results or instructions, and support medical or behavioral health workflows.
For referral coordination assignments, track referrals, gather and transmit information through approved channels, obtain required authorizations, coordinate specialty appointments, inform patients of status and next steps, and follow up on completion.
For language access assignments, provide bilingual navigation and, when separately qualified and authorized under HOPE policy, interpret spoken communication or translate written material; arrange qualified language assistance when needed.
For records and care coordination assignments, process assigned records and correspondence, obtain or document appropriate releases, support discharge follow-up and external service coordination, and respond to authorized information requests.
When assigned, participate in outreach, health fairs, patient education, resource navigation, and other community-based activities.
Perform other duties as assigned by the Team Leader to support departmental operations and organizational needs.