The Community Health Worker is responsible for encouraging patient and provider shared decision-making, promoting healthy patient behaviors that reduce risk, improving medication adherence, furthering patient self-management skills and linking the clinical care provided by the Health Center with community-based social supports.

Essential Duties & Responsibilities:  

  • Work cooperatively with other staff in coordinating patient care and pursuing team-based approaches to service delivery
  • Provide linkages for services in community partner agencies to support patients/families social needs.
  • Assist in identifying and engaging patients which would benefit from CHW support.
  • Establish trusting relationships with patients and their families while providing support, appropriate accountability and encouragement.
  • Conduct comprehensive screening/assessment activities including health status, health risks and social needs factors.
  • Engage patients/families in the development/maintenance and activation of a comprehensive treatment and self-management plan.
  • Provide ongoing follow-up, motivational interviewing and goal setting with patients/families.
  • Update Community Resource Manual on a regular basis.
  • Establish an ongoing/ trusting relationship with community partners and knowledge of their resources.
  • Be knowledgeable of CHW policies and procedures.
  • Meet patients in their home, if necessary.
  • Maintain documentation of communications via the electronic medical record (EMR). By providing appropriate documentation regarding patient visits, phone notes, patient education, resource information, provider/patient response, etc.
  • Appropriate documentation of self-management plan(s), goal setting, and follow-up conversations.
  • Maintains proficiency in the use of the EMR
  • Receive and return phone calls from patients for information gathering, updates regarding care management meetings, etc.
  • Meet monthly productivity goals.
  • Documentation during EMR down time
  • Completion of EMR down-time processes as appropriate
  • Must perform proper documentation on a CHW downtime note and be able to also properly document on downtime phone notes.
  • Participates in continuing education services, meetings, mandatory in-services, and performance improvement/OSHA programs
  • Maintains patient privacy and protects operations by keeping patient care information confidential in accordance with HIPAA.
  • Serves and protects the health center by adhering to professional standards, policies and procedures, federal, state, and local requirements.
  • Maintains safe, secure, and healthy work environment by following, and enforcing standards and procedures, complying with legal regulations and OSHA/MIOSHA.


  • 401(k)
  • 401(k) matching
  • Dental insurance
  • Flexible schedule
  • Flexible spending account
  • Health insurance
  • Health savings account
  • Life insurance
  • Paid time off
  • Vision insurance


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