Community Health Worker (CHW)

Position/Title: Community Health Worker (CHW)

Reporting/Department Head: Director of Quality and Population Health Services

*FLSA Status – Non-Exempt

*EEO Category – Service Workers

This is a full-time, grant-funded position through October 30, 2026, with the possibility of extension contingent upon continued grant funding and approval.

Our Mission: To improve lives by providing convenient, comprehensive, high-quality healthcare to every person in every community that we serve.

Our Vision: CCHN will maintain its position as the leading community health center in the state and become a model for all other healthcare organizations to follow.

MAJOR FUNCTION:

Community Health Workers use their unique position as trained community members to provide trust-based information and focused education, help clients (patients) cope with and overcome fear, walk clients through the often-complex healthcare system, and help them strategize to manage the logistics of caring for oneself in the context of a complicated life.

CHWs will work in daily coordination with physicians, nurses, and behavioral health providers, documenting all activities in CCHN’s NextGen Electronic Health Record (EHR) and participating in team huddles and care planning.

QUALIFICATIONS:

• A high school diploma or GED is required for this position.
• A valid driver’s license is required for this position.

Preferred:

• Associates degree in health or social services
• 2+ years of experience in providing supportive services
• Experience with patients with substance abuse
• Bilingual (Spanish/English) preferred

ESSENTIAL RESPONSIBILITES:

1. SDOH Screening and Needs Assessment

Administer the PRAPARE (Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences) SDOH screening tool to patients at enrollment and at each subsequent CHW encounter, using CCHN’s NextGen EHR integration. Document all results and flag positive screens for care team review.

• Screen =85% of assigned clients for social determinants of health
• Develop individualized SDOH action plans based on screening results
• Conduct follow-up assessments to monitor changes in SDOH status over time
• Identify and document unmet needs across domains including food access, housing, transportation, benefits, and behavioral health

2. Care Coordination and Patient Navigation

Serve as the longitudinal point of contact for patients with complex social and health needs within the PCMH care team, bridging clinical care and community resources.

• Receive warm referrals from physicians, nurses, and behavioral health providers at care team huddles
• Contact patients between clinic visits to assess barriers, reinforce care plans, and provide support
• Track patients with chronic conditions — diabetes, hypertension, COPD, CHF — for care gap closure using the EagleDream population health dashboard
• Coordinate medical transportation and appointment scheduling for patients with mobility or transportation limitations
• Navigate patients through complex multi-system care pathways including primary care, specialty care, behavioral health, and social services
• Document all CHW encounters in NextGen EHR to ensure care team visibility and continuity of care

3. Community Resource Linkage and SDOH Needs Closure

Connect patients with community resources to directly address identified SDOH needs, with a goal of resolving =70% of identified needs through documented services or referrals.

• Food Insecurity
• Refer patients to FeedNJ food distribution events and local food pantries
• Assist with SNAP enrollment through Cumberland County Board of Social Services
• Connect eligible patients with WIC and other nutrition assistance programs
• Housing Instability
• Connect patients with Gateway Community Action for housing stability and utility assistance
• Navigate county emergency housing programs and tenant assistance resources
• Transportation Barriers
• Coordinate NJ Medicaid transportation broker services
• Provide appointment scheduling support tailored to transportation constraints
• Benefits Navigation
• Assist patients with Medicaid/CHIP and SNAP enrollment
• Connect patients with health insurance marketplace resources and utility assistance programs
• Behavioral Health Linkage
• Facilitate warm handoffs to CCHN behavioral health providers and community mental health partners
• Support patients in navigating substance use disorder treatment resources

4. Health Education and Promotion

Deliver structured, culturally responsive health education to individuals and small groups on priority chronic disease and preventive health topics. All educational materials will be available in English and Spanish at appropriate health literacy levels.

• Chronic disease self-management: diabetes, hypertension, heart disease, COPD
• Prenatal and postpartum health; support for patients in CenteringPregnancy® program
• Mental health awareness and stigma reduction
• Preventive care: cancer screenings, immunizations, dental health
• Healthy nutrition, food-as-medicine concepts, and physical activity
• Medication adherence strategies and management
• Tobacco cessation support and resources

5. Community Outreach and Engagement

Conduct community-based outreach to identify and engage patients who face the greatest barriers to accessing clinic-based care, including uninsured individuals, MSFW families, older adults with mobility limitations, and justice-involved individuals.

• Participate in at least 4 community outreach events during the grant period, including health fairs and co-located outreach at FeedNJ distribution events
• Conduct outreach in collaboration with faith communities, county agencies, and community-based organizations in Bridgeton, Millville, Vineland, and Wildwood
• Engage migrant seasonal farmworker (MSFW) populations in Cape May County, providing bilingual services and connection to CCHN’s Wildwood site
• Support outreach to individuals released from Cumberland County Jail, facilitating primary care linkage within 30 days of release
• Build trusting relationships with populations who historically distrust or face structural barriers to healthcare systems

6. Person-Centered Goal setting and Client Empowerment

Utilize motivational interviewing, strengths-based engagement, and person-centered goal-setting to support client self-efficacy and long-term health behavior change.

• Assist patients in identifying barriers to health goals and developing individualized action plans
• Monitor patient progress, celebrate milestones, and adjust strategies as needed
• Document client-centered goals and progress in NextGen EHR
• Apply trauma-informed and culturally humble engagement practices in all patient interactions

7. Community-Clinical Partnership Support

Serve as the day-to-day operational link between CCHN and its community partner network, supporting warm referrals, tracking outcomes, and participating in inter-agency coordination.

• Maintain working relationships with partner organizations including FeedNJ, Gateway Community Action, NJ 211, Cumberland County Board of Social Services, and local behavioral health providers
• Participate in at least 1 inter-agency care coordination meeting per month with health systems and community-based organizations
• Track referral outcomes and communicate results back to the care team and partner organizations

8. Documentation and Data Collection

Maintain accurate, complete, and timely documentation to support quality improvement, outcomes monitoring, and NJDOH grant reporting requirements.

• Document 100% of CHW encounters in NextGen EHR in a timely manner
• Record SDOH screening results, referrals made, and needs closure status in EagleDream Health platform
• Contribute to monthly data reviews with the Program Director
• Support completion of NJDOH progress reports by providing accurate activity data and client counts
• Participate in rapid-cycle improvement processes when program metrics deviate from targets

The above job description is not to be construed as a complete listing of the assignments that may be given to any employee, nor are such assignments restricted to those precisely listed in the description.

EOE

CompleteCare offers full-time and part-time employees a variety of generous benefits, including but not limited to:

• Comprehensive medical, dental, and vision insurance
• Paid time off (vacation, sick leave, and holidays)
• 401(k) retirement plan with employer matching
• Incentive program
• Life and disability insurance
• Employee Assistance Program (EAP)
• Continuing education and professional development opportunities
• Flexible Spending Accounts (FSA)
• Tuition reimbursement
• Reimbursement for licensure and certifications
• Reimbursement for CPR
• Discounted services
• Employee recognition programs
• HRA/Ameriflex (covers most out of pocket expenses)
• Pension plan
• Cancer Policies
• Employee Paid Life insurance, 2 times annual salary up to $150K (CCHN paid benefit)
• AAA (discounted Rates
• BJ’s Wholesale Club (Discounted Rates)
• Direct Deposit
• Child Care Reimbursement Program
• Intersite Travel