High Risk Community Health Worker - Full Time - Days

Best Care•Council Bluffs, IA

10d•Onsite

About The Position

At Nebraska Methodist Health System, we focus on providing exceptional care to the communities we serve and people we employ. We call it The Meaning of Care – a culture that has and will continue to set us apart. It’s helping families grow by making each delivery special, conveying a difficult diagnosis with a compassionate touch, going above and beyond for a patient’s needs, or giving a high five when a patient beats a disease or conquers a personal health challenge. We offer competitive pay, excellent benefits and a great work environment where all employees are valued! Most importantly, our employees are part of a team that makes a real difference in the communities we live and work in. Job Summary: Location: Methodist Jennie Edmundson Address: 933 E. Pierce St. - Council Bluffs, IA Work Schedule: Primarily daytime hours 8-430pm. Some work outside of normal working hours required. The High Risk Community Health Worker is a key connector within the Caring for Our Communities (CFOC) initiative, designed to address gaps in care for individuals frequently cycling between emergency services, homelessness, and the Pottawattamie County Jail. Embedded directly within the Jail, with regular presence at New Visions Homeless Shelter and MICAH House, this role strengthens communication and coordination across systems often serving the same individuals in crisis. Builds trusted relationships, supports continuity of care, and helps align addiction services, healthcare, housing, and social services around shared individuals and goals. Through intentional collaboration and follow-up, this role aims to improve outcomes while reducing fragmentation and repeated crisis-driven interactions.

Requirements

Bachelor’s degree in Social Work or related field OR equivalent combination of education/experience combined required.
Obtain C3 De-Escalation certification within one year required.
Two years working with individuals affected by mental health, substance abuse, or homelessness experience required.
Valid Driver’s license and own mode of transportation at time of hire and throughout employment required.
Knowledge of government-based resources offered and criteria
Knowledge of basic health, social determinants, and social work principals.
Screen for and make referrals to address social determinants of health, such as housing, transportation, and food insecurity.
Strong interpersonal and collaborative skills.
Flexible and adaptable to change with a rapidly changing health-care environment.
Ability to work independently as well as part of a team.
Ability to communicate effectively both verbally and in writing.
Ability to be agile in addressing individual, team and community needs.
Ability to support vulnerable individuals of all ages, typically from underserved, low-income communities in urban, suburban, and rural areas.
Utilizes computer and word processing software in preparing reports, correspondence, and progress notes on individuals

Responsibilities

Provide ongoing case management services, including follow-up with individuals and partner organizations to support continuity of care and engagement.
Document interactions, referrals, and outcomes; collect and report required data points in accordance with grant requirements and program guidelines.
Screen for social determinants of health and barriers impacting individual outcomes, including mental health needs, substance use, transportation, housing instability, and food insecurity. Address identified needs by connecting individuals to appropriate community-based programs and resources through the Unite Us platform and other referral pathways.
Assess, identify, and strengthen connections to recovery and treatment resources by mapping available services, understanding referral patterns, and supporting individuals in accessing appropriate options as they become available.
Work as part of the Caring for Our Communities (CFOC) team to support individuals impacted by substance use, homelessness, mental health challenges, and repeated system involvement.
Coordinate with hospital personnel, including Emergency Department and behavioral health teams, to support care transitions and reduce crisis-driven utilization.
Collaborate with CFOC stakeholders to maintain an appropriate caseload and support shared accountability across partners.
Build and maintain strong relationships with frequently utilized community benefit organizations and service providers.
Assist in the facilitation and coordination of the Homeless Review Team, supporting information-sharing and cross-system case review.
Serve as a liaison and trusted resource for network providers, law enforcement, court system partners, public health, hospitals, shelters, and clinic personnel to advance coordinated, value-based care.
Establish trust and rapport with individuals in culturally and linguistically appropriate ways, serving as a consistent and trusted point of connection across systems.
Act as an advocate for the needs, rights, and interests of individuals, supporting navigation of state, federal, and local systems as needed.
Assess, identify, and strengthen connections to recovery and treatment resources by mapping available services, understanding referral patterns, and supporting individuals in accessing appropriate options as they become available.
Utilize knowledge of government assistance programs to support individuals in accessing benefits and services for which they may be eligible.
Maintain up-to-date knowledge of community resources, including shelters, support groups, food pantries, mental health treatment providers, transportation options, and financial assistance programs.
Assist individuals in applying for and utilizing services provided through state and federal agencies and local service providers.