Community Health Worker

Summary: The Community Health Worker (CHW) is a frontline public health professional who serves as a trusted liaison between patients, the hospital care team, and community-based organizations. The CHW screens patients for Health-Related Social Needs (HRSN), facilitates referrals to community and health resources, supports care coordination, and conducts community outreach to improve health outcomes and reduce avoidable utilization. 

This position is embedded within the hospital/clinic setting and works closely with patients, clinical, case management, and population health teams to address social drivers of health and advance health equity. 

Essential Duties and Responsibilities: 

1. Screening 

• Conduct standardized Health-Related Social Needs (HRSN) screenings, including food insecurity, housing instability, transportation barriers, utility needs, interpersonal safety, and nicotine use (including adolescents ages 13–17). 
• Identify patients who may benefit from chronic disease management and prevention programs (e.g., weight management, Diabetes Prevention Program (DPP), tobacco cessation). 
• Utilize hospital-approved screening tools and motivational interviewing techniques to assess patient strengths, goals, and barriers. 
• Document all screenings and patient interactions in the electronic health record (EHR) and designated data systems. 

2. Referrals 

• Provide referrals to internal hospital services and external community-based organizations. 
• Assist patients in navigating and enrolling in community resources and public benefit programs (e.g., SNAP, Medicaid, My Life My Quit). 
• Conduct closed-loop referral follow-up to ensure successful connection to services and address barriers. 
• Reinforce discharge plans, medication adherence, follow-up appointment scheduling, and transportation coordination as appropriate. 
• Collaborate with care managers, social workers, nursing staff, and providers to support patient-centered care plans. 
• Track referral outcomes, support quality improvement efforts, and submit required internal reports as well as monthly reports to the Oklahoma Hospital Association in accordance with program guidance. 

 3. Community Engagement 

• Develop and maintain partnerships with community-based organizations, social service agencies, and other local stakeholders. 
• Participate in and support community outreach initiatives to increase awareness of hospital services and available resources while fostering community trust and engagement. 
• Maintain and regularly update a resource directory tailored to the hospital’s service area. 

Required Qualifications 

·        High school diploma or equivalent required; associate’s or bachelor’s degree in public health, social work, or related field preferred. Maintain ongoing education to continue CHW certification                    

             requirements.

·        Within the first year of work, obtain certification as a Community Health Worker by completing applicable training or after 1,000 working hours, whichever comes first.

·        Experience working in community health, social services, or healthcare settings preferred.  

·        Strong knowledge of local community resources and social service systems. 

·        Excellent communication, interpersonal, and organizational skills. 

·        Ability to work effectively with diverse populations and demonstrate cultural humility.

·        Current, valid driver’s license with a clean driving record; MVR check required

Preferred Qualifications 

• Experience with electronic health record systems. 
• Bilingual or multilingual skills reflective of the community served. 
• Experience working in rural healthcare settings. 

Core Competencies 

• Cultural responsiveness and humility 
• Patient advocacy 
• Trauma-informed approach 
• Confidentiality and professionalism 
• Team collaboration 
• Resource navigation expertise 

Language/Reading Skills:

• Communicate in English verbally and in writing.
• Ability to multitask and work cooperatively with others.  

Reasoning Ability: Responds to unusual or varied situations that are not covered by existing standards, procedures and precedents. Must exercise sound judgment in the field when interacting with patients and community partners.

Work Environment: Hospital/clinic-based clinical setting with some community-based outreach. May require travel within the hospital’s service area. May include evening or occasional weekend community events. Regularly required to stand, walk, sit, ascend and descend stairs, possess ability to handle, finger or feel objects, tools or controls; reach with hands and arms. Frequently be able to lift 50 pounds from the floor to waist level and may occasionally be required to assist moving adult patients.