Population Health Community Health Worker

Description:

We are seeking a dynamic and mission-driven Population Health Community Health Worker to support our Patient Engagement Services team. This hybrid role combines community outreach, patient navigation, and population health strategies to improve access to care and health outcomes for underserved populations. This position plays a critical role in advancing preventive care, addressing social determinants of health (SDOH), and supporting value-based care initiatives, including the Medicare Shared Savings Program (MSSP). The ideal candidate is equally comfortable working in the community and conducting outreach to patients by phone.

Key Responsibilities:

Population Health & Care Gap Closure Conduct targeted outreach to patients with care gaps (e.g., mammograms, FIT kits, colonoscopies, AWVs, chronic disease follow-ups) Utilize EHR registries and reports to prioritize high-risk and MSSP-attributed patients Schedule and coordinate preventive and follow-up care to improve quality metrics Track and follow through until care gaps are closed MSSP / Value-Based Care Support Support outreach to Medicare and high-risk patients attributed under MSSP initiatives Assist with scheduling and completion of Annual Wellness Visits (AWVs) Conduct post-discharge and ED follow-up calls to support transitions of care Identify and escalate high-risk patients to care management teams (e.g., frequent ED utilizers, chronic conditions not well managed) Address barriers that may lead to avoidable hospitalizations (transportation, medication access, housing instability, etc.) Patient Navigation & Care Coordination Coordinate appointments across medical, dental, and behavioral health services Assist with referrals, including specialty care and diagnostic services Provide reminders, prep instructions (especially for procedures like colonoscopies), and follow-up Reduce no-show rates through proactive engagement and barrier mitigation SDOH Screening & Enabling Services Conduct SDOH screenings (e.g., ACH HRSN) and document in the eCW Identify and address barriers impacting care access and adherence Provide referrals and warm hand-offs to community resources Assist with applications for insurance, sliding fee programs, and social services Community Engagement Build trust with underserved populations, including immigrant, migrant, and homeless communities Provide culturally and linguistically appropriate education and support Participate in outreach events and targeted engagement initiatives Documentation & Data Tracking Document all outreach, care coordination, SDOH screenings, and referrals in the eCW Track outcomes related to care gap closure, AWVs, and MSSP-related activities Support internal quality improvement efforts

Requirements:

What We're Looking For:

Core Competencies Ability to understand risk and utilization (who needs the most attention and why) Strong follow-up and accountability Comfort discussing preventive care and chronic conditions with patients Balance between productivity (calls, metrics) and meaningful patient engagement Critical thinking—knowing when to escalate to RN care managers or providers

Required:

High School Diploma or equivalent Experience working with underserved or high-risk populations Strong communication skills (in-person and phone-based outreach) Ability to manage multiple tasks, follow up consistently, and stay organized Willingness to work flexible, evening & Saturday hours, including community-based settings

Preferred:

Community Health Worker (CHW) Certification or similar experience Bilingual (Spanish/English strongly preferred) Experience with population health, care coordination, or outreach programs