Transitions Clinic Community Health Worker

Optimus Health Care, Inc.•Bridgeport, CT

10d•Hybrid

About The Position

Optimus Health Care, the largest provider of primary health care services in Fairfield County, is seeking a full-time Transitions Clinic Community Health Worker with outreach experience for its Bridgeport, CT location. This position is 100% grant-funded and involves local travel between sites and facilities. The role focuses on community-based outreach, reentry care navigation, patient engagement, health education, social drivers of health support, and care coordination for individuals recently released from incarceration or otherwise justice-involved who are connected to Optimus Health Care. The CHW will support statewide reentry coordination for individuals transitioning from Connecticut Department of Correction facilities or similar settings, linking them to Optimus Health Care services. This non-clinical role is part of an interdisciplinary team and collaborates with various internal departments and external partners to improve patient linkage to care, appointment attendance, retention, medication access, chronic disease management, and substance use linkage. The position is crucial for patient engagement, trust-building, navigation, advocacy, and follow-through.

Requirements

High school level education; Two years of related work experience and an associate’s degree; or a bachelor’s degree in a related field; or an equivalent combination of experience and education.
Related experience in community outreach, peer support, reentry work, healthcare navigation, case management support, human services, behavioral health support, substance use recovery support, or social service navigation is required.
Ability to build trust with individuals with diverse justice-involvement histories and complex behavioral health, substance use, medical, and social needs.
Basic knowledge of chronic disease, reentry barriers, substance use recovery, mental health access, harm reduction, and social drivers of health.
Ability to coordinate with healthcare providers, DOC contacts, halfway houses, shelters, community-based organizations, and social service agencies.
Strong organizational skills, follow-through, reliability, attendance, time management, and ability to manage multiple patient needs and partner contacts.
Ability to document clearly and professionally in EPIC and/or other approved systems and maintain program-defined grant tracking data.
Comfort working in clinical, community, correctional, shelter, halfway house, and outreach settings when approved and appropriate.
Bilingual English/Spanish strongly preferred.
Ability to communicate with patients, staff, and community partners using tactful, culturally responsive, trauma-informed, and nonjudgmental communication in sensitive or emotional situations.
Community Health Worker certification preferred but not required. If not already certified or trained as a CHW, willingness and ability to complete CHW training within the first 90 days of employment or within the timeframe approved by the supervisor.
Valid and verifiable Connecticut driver’s license, good driving record, and reliable transportation required.
Ability to travel to Optimus sites, approved community locations, halfway houses, shelters, partner agencies, and DOC facilities when permitted and required.
Ability to meet requirements for entry into DOC facilities and partner sites when applicable, including background checks, facility orientation, security clearance, and site-specific protocols.
Ability to complete required Optimus, grant, compliance, safety, HIPAA, and program trainings.

Nice To Haves

Experience working with formerly incarcerated or justice-involved individuals.
Experience in an FQHC, community health center, primary care, behavioral health, substance use treatment, reentry, shelter, housing, or community-based organization.
Familiarity with Medicaid/HUSKY, SNAP, housing resources, employment resources, transportation systems, and community-based services.

Responsibilities

Conduct outreach, engagement, and navigation for individuals recently released from incarceration or otherwise justice-involved who have chronic medical, behavioral health, substance use, and social needs.
Support statewide reentry coordination for patients released from Connecticut DOC facilities or other justice-related settings when they are connected or expected to link to Optimus/Bridgeport services.
Conduct in-reach/outreach inside DOC facilities when permitted by DOC, Optimus policy, grant scope, facility requirements, and supervisor approval.
Coordinate with DOC contacts, halfway houses, shelters, reentry programs, probation/parole contacts when appropriate, and community partners to identify eligible patients and support continuity of care.
Recruit and engage eligible patients for the Transition Clinic program using program-approved outreach workflows and referral pathways.
Assist patients with linkage to Optimus primary care and related services, including appointment scheduling, appointment reminders, visit preparation, warm handoffs, and follow-up after missed visits.
Support care coordination for priority health areas, including HIV, hepatitis C, diabetes, hypertension, substance use disorder, mental health, medication access, preventive care, and primary care linkage.
Provide health education and self-management support using non-clinical, culturally responsive, trauma-informed, and patient-centered approaches.
Use motivational interviewing, harm reduction principles, and nonjudgmental communication to support patient goals, engagement, and readiness for care.
Provide harm reduction and recovery support, including overdose prevention education, naloxone education/referral, MOUD/Sublocade linkage support, relapse-prevention encouragement, and referral to substance use treatment as appropriate.
Assist with social drivers of health screening and stabilization needs, including Medicaid/HUSKY access, SNAP, identification documents, housing referrals, employment resources, food, clothing, phone access, transportation resources, and medication access.
Coordinate transportation resources for appointments and services, including identifying barriers, helping patients schedule rides, confirming pickup and appointment logistics, and documenting transportation needs. Direct patient transportation is not routine and may occur only when approved by the program, supervisor, and Optimus policy.
Make referrals and warm handoffs to community resources and follow up to support connection, completion, and problem-solving when barriers arise.
Document outreach, patient contacts, referrals, barriers, follow-up, and care coordination activities in EPIC and/or other approved systems in a timely manner according to Optimus policy and program standards.
Maintain recruitment logs, linkage outcomes, appointment attendance support, referral follow-up, outreach activity, patient engagement updates, and other program-defined grant tracking data.