Department: Medical Support
Position: Community Health Work (CHW)
Employee Category: Non-Exempt
Reporting Relationship: Care Management Manager
Character Qualities:
- Initiative: Recognizing and doing what needs to be done before I am asked to do it.
- Gentleness: Demonstrates respect, empathy, and concern for patients and families
- Flexibility: Adapts to changing patient and system needs without loss of focus
- Responsibility: Demonstrates accountability, reliability, and follow-through
- Integrity: Acts with honesty, professionalism, and sound judgment
Summary of Duties and Responsibilities:
The Community Health Worker (CHW) is a frontline, relationship-based Population Health team member and a trusted member of, or one who has a close understanding of, the community served. The CHW serves as a liaison between patients, families, the care team, and the community, working to improve access, health literacy, engagement, and outcomes across the full Variety Care patient experience.
This role integrates the ten core CHW roles and eleven core skill areas defined by the Community Health Worker Core Consensus (C3) Project - the national framework referenced by the Oklahoma Community Health Worker Act and used by the Oklahoma Health Care Authority (OHCA) to define CHW scope of work. The CHW works in close collaboration with clinical teams, care management, behavioral health, and community partners to reduce avoidable emergency department utilization, close gaps in care, and support Variety Care's value-based care and Patient-Centered Medical Home (PCMH) goals.
The CHW maintains structured, longitudinal engagement with a defined panel of high-risk and rising-risk patients while also conducting broader outreach, health education, and capacity-building activities that extend Variety Care's reach into the community.
Primary Duties and Responsibilities:
Outreach & Case-Finding
- Conducts proactive outreach and case-finding to identify and connect eligible individuals, families, and community groups to Variety Care services, including through home visits, community events, and partner agencies.
- Builds and maintains a current resource inventory of community assets, social services, and referral partners relevant to the assigned patient population.
- Prepares and disseminates outreach and health education materials to patients and community members.
Patient Navigation & Care Coordination
- Guides patients through healthcare processes including scheduling, referrals, follow-up care, and connection to internal and external resources.
- Identifies barriers to care across the patient journey - clinical, social, financial, transportation, and digital access - and works to resolve them.
- Tracks referrals and ensures timely closure, escalating unresolved barriers per Population Health workflows.
- Supports post-ED and post-hospital transitions by ensuring timely follow-up with primary care, medication access, and continuity of care.
- Coordinates CHW activities with clinical staff and other community-based services to support a unified care plan.
Direct Services & Basic Support
- Provides basic screenings (e.g., height, weight, blood pressure) and basic supportive services (e.g., first aid, diabetic foot checks) within the defined scope of the role and applicable training.
- Assists patients in meeting basic needs by connecting them to direct provision of food, housing, and other essential resources.
- Supports telehealth utilization by helping patients understand and access virtual visit options when appropriate.
Longitudinal Engagement & Patient Activation
- Maintains ongoing, relationship-based engagement with an assigned panel of high-risk and rising-risk patients.
- Utilizes motivational interviewing and coaching techniques to assess readiness for change, support patient goal setting, and reinforce engagement with care plans.
- Encourages patient self-management and active participation in care without providing clinical counseling or case management.
- Plans or co-leads patient support groups, classes, and community presentations on relevant health topics.
Cultural Mediation & Health Education
- Serves as a cultural mediator between patients, families, and the health system, supporting understanding of how to access and use health and social service systems.
- Provides culturally and linguistically appropriate health education and disease prevention information matched to the needs of the individual or community.
- Educates internal teams and systems about community perspectives, cultural norms, and Culturally and Linguistically Appropriate Services (CLAS) standards.
- Maintains current knowledge of Variety Care services, community resources, and culturally responsive practices relevant to the assigned patient population.
Advocacy & Capacity Building
- Acts as a patient advocate and liaison between patients, families, providers, and care teams to ensure patient-centered goals remain the focus.
- Advocates for the needs and basic resource access (e.g., food, housing) of individuals and communities served.
- Builds individual and community capacity by teaching self-advocacy skills and supporting peer and community networks.
- Initiates and maintains collaborative relationships with internal teams and external community partners to support warm handoffs and continuity.
Assessment, Evaluation & Escalation
- Participates in individual-level assessments (e.g., home environmental assessments) and community-level assessments (e.g., community asset mapping) as assigned.
- Identifies psychosocial or environmental factors impacting patient engagement and escalates appropriately to behavioral health, care management, social services, or clinical staff using defined workflows.
- Contributes to evaluation of CHW program activities and outcomes, including data collection and sharing of findings with Population Health leadership.
- Conducts community-based outreach or home visits, targeted to high-risk patients and approved by Population Health leadership.
Documentation, Data & Population Health
- Utilizes the electronic health record (EHR) for all documentation, referrals, patient contacts, and care coordination activities in a timely manner.
- Communicates patient progress, barriers, and outcomes clearly to care teams and Population Health leadership.
- Collaborates with the Population Health team on value-based care initiatives and payer-related projects as assigned, including Medicaid CHW service billing requirements where applicable.
Professional Standards & Compliance
- Adheres to HIPAA, OSHA, the CHW Code of Ethics, and Variety Care policies related to privacy, safety, and confidentiality.
- Identifies situations requiring mandatory reporting and carries out mandatory reporting responsibilities as required by law.
- Sets appropriate professional boundaries and practices self-care to sustain effectiveness in a relationship-based role.
- Supports Variety Care's accreditation as a Patient-Centered Medical Home and its commitment to safe, effective, patient-centered, timely, efficient, and equitable care.
- Participates in required training, team meetings, continuing education, and quality improvement activities.
- Performs other duties as assigned within the defined scope of the role.
The CHSN role is focused on navigation, engagement, and barrier resolution in support of Population Health and value-based care outcomes.