Community Health Worker

Community Health Worker (CHW) – In-Home Medical Practice
Employment Type: Full-Time or Part-Time

Make a Meaningful Impact Where Patients Need It Most

Join a compassionate, mission-driven in-home medical practice dedicated to improving the health, independence, and quality of life of our patients. As a Community Health Worker (CHW), you will play a vital role in helping patients overcome social and environmental barriers that affect their ability to receive and benefit from medical care.

Working alongside providers, care managers, and families, you will serve as a trusted advocate, helping patients navigate complex social systems while connecting them to essential community resources.

What You'll Do

Support & Assess Patient Needs

• Conduct Social Determinants of Health (SDOH) screenings in patient homes, by phone, or virtually
• Identify barriers related to food access, transportation, housing stability, utilities, home safety, social isolation, and financial hardship
• Build strong, trusting relationships through culturally responsive, trauma-informed care

Connect & Advocate

• Link patients and families with community resources such as food programs, transportation, housing support, and social services
• Assist with applications for public benefits (SNAP, Medicaid-related programs, disability, aging services, etc.)
• Advocate for patients to improve access to services and support

Coordinate Care

• Partner with providers, nurses, and care teams to align social support with medical care plans
• Facilitate communication between patients, caregivers, community agencies, and the clinical team
• Track referrals, monitor outcomes, and adjust support plans as patient needs change

Support Safe Home Environments

• Identify home safety risks that impact patient health and independence
• Coordinate referrals for home modifications, medical equipment, and supportive services
• Help patients and caregivers problem-solve daily living challenges

Document & Maintain Compliance

• Accurately document patient interactions, referrals, and outcomes in Athena EHR
• Stay current on community resources and eligibility requirements
• Maintain strict confidentiality and HIPAA compliance

What You Bring

Required

• High school diploma or equivalent
• Active Community Health Worker certification
• Experience working with aging, vulnerable, or medically complex populations
• Knowledge of community resources and public assistance programs
• Strong communication, organizational, and relationship-building skills
• Ability to work independently and as part of a collaborative care team
• Valid drivers license and reliable transportation

Preferred

• Associates or Bachelors degree in Social Work, Public Health, Human Services, or related field
• Experience in home-based care, primary care, or care management
• Bilingual (English/Spanish)

Work Environment

• Hybrid role combining field visits and remote patient engagement
• Collaborative, interdisciplinary in-home medical care team
• Mix of in-person, phone, and electronic patient support

Why Join Us?

We believe healthcare should meet patients where they are — physically, emotionally, and socially. In this role, you will directly improve patients lives by helping remove barriers to care, promoting independence, and supporting long-term wellness in the home. Your work will create real, lasting change for patients and families every day.