Community Health Worker - Population Health
Job Type

Works as part of a team-based health care delivery model to provide coordinated and comprehensive patient outreach and care coordination that follows the Patient-Centered Medical Home model – specifically focused on supporting patients to address adult chronic disease prevention and management. The Community Health Worker will use their expertise in health and social service resources to help individuals experiencing health inequities connect to needed services. The Community Health Worker will also serve as a link between the patient and appropriate agencies.



• Engage and educate community about chronic disease prevention and management, including referral to community lifestyle management programs

• Act as a link between patients and health care, both in and outside of Vibrant Health

• Complete Community Health Worker Certification course within 6 months of being hired

• Complete Blood Pressure Self-Monitoring Program training, Healthy Heart Ambassador training and/or Diabetes Prevention Program lifestyle coach training as designated by supervisor

• Conduct the National Diabetes Prevention Program as a Lifestyle Coach once the program is established

• Assist participants with logging their self-measured data and reporting that data to medical professionals

• Learn and apply clinic policies and procedures to Population Health team work

• Protect patient information and maintain confidentiality according to HIPAA guidelines

• Engage in relationship-building discussions with patients to find out if there are barriers to health care, create action plans to address and overcome barriers through internal or external referral

• Uplift patients’ ability to self-navigate or reach out to resources now and in the future with services like peer education, peer support, advocacy, problem-solving, resource connection

• Create patient tracking and follow-up systems as part of clinical workflows, supporting team-based care

• Log enrollments and navigation contacts into practice health record and social service database

• Participate in daily clinic and weekly Population Health Team huddles, providing integrated care

• Participate in community action planning and partnerships to address chronic disease health equity

• Provide public health education and resources at community events

• Complete monthly reports to track enrollments, contacts, success stories, systems barriers

• Collaborate with Population Health Team to develop end-of-year success stories

·Carries out Vibrant Health’s mission to provide access to respectful, empowering, culturally sensitive and appropriate high-quality health care for the community, regardless of socio-economic obstacles.

Accepts and uses supervision, direction and consultation to maximize available resources in the completion of work duties.

All job responsibilities will be carried out under the direction of the organization’s policies and procedures.

Additional responsibilities may be assigned as needed to maintain and improve effective functioning of the department and to advance the mission of the organization.

At Vibrant Health, we understand that many, if not most, people have experienced trauma in their lives. We have made a commitment to trauma informed care and support and educate team members continued development of understanding of how trauma affects individuals and coping strategies. We expect employees to incorporate their understanding about trauma into interactions with our patients and families, clinic visitors, and with each other.


High school diploma or equivalent plus and lived experience or close connection to the community being served. Skill or willingness to learn use of personal computers, Microsoft Office software, and electronic health record technical skills.

Individual must:

1. Develop rapport with patients and their families, community and other health care personnel.

2. Exhibit a professional and respectful demeanor.

3. Work successfully independently and within a team, shifting tasks, prioritize tasks, problem-solve daily, and complete work within deadline.

4. Demonstrate excellent customer service, helpfulness, and a positive attitude.

5. Possess superior organizational skills with attention to detail and the ability to multi-task and meet deadlines.

6. Demonstrate the ability to recognize, understand, and appreciate the value of cultural diversity.

7. Demonstrate social and cultural sensitivity to ethnically and economically diverse patients and staff.

8. Exhibit experience and working knowledge of local community resources.

9. Hold current drivers’ license with an acceptable driving record, and reliable transportation.

10. Travel to all parts of the facility and throughout the community.

11. Will be required to have current CPR certification, which can be provided through Vibrant Health if needed.

12. Proficiency in use of personal computers and Microsoft Office (Outlook, Word and Excel).


Working knowledge of electronic health records, medical terminology, and third-party health care coverage preferred. Prior experience working in a health care environment.

Oral and written fluency in Spanish or a language other than English highly preferred.


Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands and fingers to handle or feel objects, tools or controls; reach with hands and arms; climb stairs; talk and hear. The employee must frequently lift and/or move materials that may weigh up to 40 pounds. The employee will be required to move between facilities and when appropriate, patients’ homes.

Work Environment

Work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Must have manual dexterity and experience to perform handwritten paper work, recordkeeping, and filing.

• Prolonged sitting, standing, or walking may be required.

• Frequent bending/stooping, squatting, reaching above the shoulders, twisting and turning, kneeling, and pushing/pulling may be required.

• Employment is contingent upon successful clearance from Criminal, Kansas and Missouri Child/Elder Abuse and Neglect, Sex Offender background investigations, TB testing, pre-employment drug testing, and verification of Hepatitis-B, flu and COVID-19 immunizations.

• Occasional evening and weekend availability are required.

Commitment to Diversity

We are proud to be an Equal Employment Opportunity (EEO) and Vietnam Era Veterans Readjustment Assistance Act (VEVRAA) Employer. We are committed to cultivating a workplace in which diverse perspectives and experiences are welcomed and respected. We do not discriminate on the basis of race, color, religion, creed, ancestry, national origin, sex, age, disability (physical or mental), marital or veteran status, genetic information, sexual orientation, gender identity, political ideology, or membership in any other legally protected class. We are an Affirmative Action employer. We encourage individuals with diverse backgrounds to apply and desire priority referrals of protected veterans. If due to a disability you need assistance/and or a reasonable accommodation during the application or recruiting process, please send a request to