Community Health Worker - Care Manager

Position Summary:

Under the leadership and direction of the Director of Population Health, the Care Manager - Community Health Worker (CHW) helps patients with complex medical and social needs access care and community services. The CHW conducts outreach, builds trusted relationships, identifies and addresses barriers to complex health resources, and coordinates care transitions. Responsibilities include assisting with housing, food, transportation, and benefits, supporting follow-up after hospital visits, and promoting health equity through culturally competent care. This hybrid role involves telephonic and in-person engagement, including home and community visits, with active participation in care team planning and documentation.

Job Responsibilities and Performance Standards:

1. HRSN Screening & Follow-Up Management

• Conduct Social Drivers of Health (SDOH) screenings.


• Identify barriers to care (housing, food, utilities, transportation, financial needs).


• Develop individualized outreach and care plans in collaboration with the team.


• Help patients access services: SNAP, SSI, DTA applications


• Medicaid or other benefits


• Educational/vocational resources


• Assist in appointment scheduling and follow-up.


• Provide health education and coach patients on personal and clinical goals.


• Maintain accurate documentation of interventions and outcomes.

2. Patient Engagement

• Initiate trust-based relationships with patients, families, and caregivers.


• Use motivational interviewing, cultural mediation, and harm reduction strategies to promote engagement.


• Conduct outreach in diverse settings such as:

1. Telephonic


2. In-home visits


3. Community sites


4. Health centers

• Accompany patients to healthcare or social services appointments as needed.


• Address language and cultural barriers to care.


• Collaborate with population health and care management teams for hard-to-engage patients.


• Refer patients for health insurance enrollment or other support services.

3. Transitions of Care (TOC) Support

• Follow up on post-discharge referrals to reduce readmission risk.


• Support patients in resuming home-based services or community supports.


• Escalate barriers to the Primary Care Team to prevent avoidable ED visits or readmissions.


• Participate in pre-visit planning and care team meetings.


• Engage patients between visits to promote continuity of care.

Qualifications and Experience:

• Medical Assistant, Engagement Specialist, or Community Health Worker Certification.


• Bilingual English/Spanish speaking required.


•  Demonstrated success in working as part of a multi-disciplinary team.


• Experience working with patients with chronic medical and behavioral health needs.


• Demonstrated experience working with diverse patient populations and workforce.


• Experience within the ACO’s member population preferred, including
  Medicare/Medicaid.


• Experience working with Medicare, Medicaid, and/or Special Needs populations.


•  Must be flexible and adaptable to change.


•  Strong organizational skills with the ability to prioritize and multitask as needed.


• Demonstrate the ability to work independently.


• Must demonstrate excellent interpersonal communication skills.

GLFHC offers a great working environment, a comprehensive benefits package, growth opportunities, and tuition reimbursement.