2989952905-2 Apply for this job now Job Description Oak Street Health seeks a Community Health Worker to support Medicare patients in underserved communities. In this role, you'll conduct outreach, build trusting relationships, and connect patients with primary care and social services. You'll provide health education, support care plans, and help reduce barriers like transportation, housing, and food insecurity. Working closely with an interdisciplinary care team, you'll track patient progress, document in EHR systems, and promote preventive care-making a meaningful impact in a collaborative, patient-centered environment with room for professional growth. Responsibilities Conduct community outreach and engagement with Medicare patients in underserved areas Build trusting, culturally competent relationships with patients and caregivers Provide health education and coaching to support preventive care and chronic disease management Coordinate care and appointments with primary care providers and the care team Identify and address social determinants of health, connecting patients to community resources Support development and follow-through of individualized care plans Document encounters and patient progress accurately in EHR systems Collaborate with an interdisciplinary team to improve patient outcomes and access to care Monitor patient adherence and follow-up, conducting home or community visits as needed Participate in quality improvement and population health initiatives Required Skills Community outreach Care coordination Patient education Basic clinical screening (vitals, risk assessments) Electronic health records (EHR) use Data entry and documentation Cultural competency Motivational interviewing Health coaching Resource navigation (social services)