JOB SUMMARY

The Community Health Worker (CHW) serves as a vital link between patients, healthcare providers, and community resources to improve health outcomes and access to care throughout the Hocking Valley region.

Working as an integral member of the Rural Health Clinic interdisciplinary team, the CHW assists patients in overcoming barriers to healthcare, navigating the healthcare system, accessing community resources, and managing their health conditions.

The CHW focuses on identifying and addressing social determinants of health, including transportation, food insecurity, housing instability, financial barriers, medication access, insurance coverage, and other challenges that may prevent patients from achieving optimal health.

This position supports HVCH’s mission to provide accessible, compassionate, patient-centered healthcare while strengthening the health of the rural communities it serves.

ESSENTIAL FUNCTIONS

1. Patient Navigation and Care Coordination

• Assist patients in navigating the healthcare system and accessing appropriate services.
• Help patients schedule primary care, specialty, diagnostic, and follow-up appointments.
• Follow up with patients following hospital discharge, emergency department visits, and clinic appointments as directed.
• Assist patients with understanding their care plans and connecting with appropriate healthcare services.
• Identify patients at risk for missed appointments, delayed care, or avoidable emergency department utilization.
• Communicate patient needs and barriers to providers, nurses, and care coordination staff.
• Support transitions of care between hospital, primary care, specialty services, and community providers.

2. Social Determinants of Health

• Screen patients for social needs and barriers affecting their health.
• Connect patients with local, county, state, and federal assistance programs.
• Maintain an updated directory of community resources and referral contacts.
• Assist patients with navigating applications for available assistance programs.
• Identify needs related to:
• Food insecurity and nutritional assistance.
• Housing instability and utility assistance.
• Transportation to medical appointments.
• Insurance enrollment and financial assistance.
• Medication affordability and access.
• Employment and financial instability.
• Access to behavioral health and substance use services

3. Chronic Disease Management and Preventive Health

• Support clinic initiatives focused on diabetes, hypertension, obesity, cardiovascular disease, and other chronic conditions.
• Encourage patients to participate in preventive screenings and routine wellness visits.
• Conduct follow-up outreach to patients who are overdue for appointments, laboratory testing, or recommended screenings.
• Reinforce provider-directed education and self-management plans.
• Assist with patient outreach for quality improvement initiatives and population health programs.
• Promote healthy lifestyle choices, including nutrition, physical activity, smoking cessation, and preventive healthcare.

4. Community Outreach and Engagement

• Develop relationships with community organizations, social service agencies, schools, churches, and other local partners.
• Participate in community health fairs, wellness events, and health education activities.
• Help identify unmet healthcare needs within the community.
• Support HVCH community health improvement initiatives.
• Promote awareness of Rural Health Clinic services and available hospital programs.
• Serve as a trusted resource and advocate for individuals and families experiencing barriers to healthcare.

5. Patient Advocacy and Education

• Build trusting relationships with patients through compassionate, culturally sensitive communication.
• Advocate for patients who may have difficulty navigating the healthcare system.
• Provide education and assistance within the CHW scope of practice.
• Encourage patient engagement and participation in healthcare decisions.
• Maintain patient confidentiality and comply with HIPAA and hospital policies. 

6. Documentation and Performance Monitoring

• Document patient interactions, referrals, outreach, and follow-up activities in the electronic health record as appropriate.
• Maintain accurate records of community resource referrals and patient outcomes.
• Track successful connections to community resources.
• Monitor patient engagement and follow-up completion.
• Participate in quality improvement and population health initiatives.
• Assist with reporting requirements associated with grants, community health programs, and reimbursement initiatives.

Performance Expectations and Key Performance Indicators

The CHW will be evaluated based on measurable contributions to patient access, engagement, and community health outcomes.

Performance measure

Suggested target

Patients receiving social needs screening - 90% of assigned patients

Successful community resource referrals - 75%

Post-discharge patient outreach - Within 2–3 business days

Follow-up on identified patient barriers - 90%

Outreach to patients overdue for preventive care - Monthly

Documentation of patient encounters - 95%

Community outreach participation - Quarterly

Targets should be adjusted based on staffing, patient population, payer requirements, and program volume.

Working Relationships

The Community Health Worker will work closely with:

• Rural Health Clinic physicians and advanced practice providers.
• Registered nurses and licensed practical nurses.
• Clinic practice manager.
• Hospital case management and discharge planning.
• Social services and behavioral health providers.
• Population health and quality improvement personnel.
• Community agencies and nonprofit organizations.

FUNCTIONAL DEMANDS

• Ability to travel within the community for outreach activities as assigned.
• Ability to sit, stand, walk, and communicate effectively throughout the workday.
• Valid Ohio driver’s license and reliable transportation if community-based visits are required.

QUALIFICATIONS AND REQUIREMENTS

Education

High school diploma or GED required.

Associate degree in healthcare, social services, human services, or related field preferred.

Certification

Ohio Community Health Worker certification preferred or willingness to obtain certification within an established timeframe.

Experience working with underserved or rural populations preferred.

Experience

Previous experience in healthcare, social services, community outreach, case management, or patient navigation preferred.

Knowledge of community resources and social service programs in Hocking County and surrounding counties preferred.

Experience working with diverse populations and individuals experiencing socioeconomic barriers.

Required Skills and Competencies

Excellent interpersonal and communication skills.

Strong organizational and time-management abilities.

Compassionate, patient-centered approach.

Ability to establish trust and rapport with patients.

Knowledge of community resources and social support programs.

Ability to work independently and collaboratively with an interdisciplinary healthcare team.

Basic computer skills and familiarity with electronic medical records.

Ability to maintain confidentiality and professional boundaries.

Problem-solving and resourcefulness.