Job Description

Description

The Community Health Worker (CHW) serves as the field-based extension of the interdisciplinary care team as part of the Care at Home Solutions program. The CHW partners closely with the Medical Director, Advanced Practice Provider (APP), Registered Nurse (RN), Pharmacist, and Care Navigators to help patients overcome barriers to care, improve health outcomes, and remain engaged in achieving goals of care. CHWs conduct home visits, support collection of non-diagnostic health information, assist with technology and telehealth access, and connect patients to community-based resources.

Duties and Responsibilities (including but not limited to)

• Conducts home visits and community-based outreach to engage patients in care and support ongoing participation in the Care at Home program.
• Establishes trusting relationships with patients, caregivers, and family members.
• Identifies social determinants of health (SDOH) needs and barriers to care, including transportation, food insecurity, housing instability, social isolation, and technology access.
• Connects patients with appropriate community resources, social services, and support programs.
• Assists patients with scheduling appointments and accessing healthcare services.
• Supports telehealth visit readiness, including assistance with technology setup and patient education.
• Performs protocol-driven collection of non-diagnostic health information, including vital signs, weight, blood pressure, pulse oximetry, and other approved biometric measurements.
• Documents observations and patient-reported concerns and communicates findings to licensed clinical team members.
• Provides appointment reminders and follow-up outreach to improve care engagement and reduce missed visits.
• Supports Annual Wellness Visit (AWV) completion and quality gap closure initiatives through patient outreach and engagement activities.
• Assists patients in understanding care plans and following provider recommendations.
• Accompanies patients to appointments or community resource visits when appropriate.
• Participates in interdisciplinary care team meetings and case discussions.
• Maintains accurate and timely documentation within the Electronic Medical Record (EMR) and other designated systems.
• Serves as a patient advocate and liaison between patients, families, providers, and community organizations.
• Maintains patient confidentiality and complies with all HIPAA and organizational requirements.

Scope of Role

• Does not perform clinical triage. 
• Does not provide medical advice.
• Does not perform clinical assessments or nursing functions.
• Escalates all clinical concerns to licensed clinical personnel in accordance with organizational protocols and California scope-of-practice requirements.

Qualifications or Education, Training and Experience

• High school diploma or equivalent required.
• Community Health Worker certification or formal CHW training preferred.
• Minimum one (1) year of experience working in healthcare, community outreach, social services, care coordination, or a related field preferred.
• Experience working with Medicare Advantage, older adults, or medically complex populations preferred.
• Bilingual English/Spanish preferred.
• Valid California Driver's License, reliable transportation, and proof of insurance required.
• Ability to travel throughout assigned service areas for home visits and community outreach.
• Basic computer proficiency required; Electronic Medical Record (EMR) experience preferred.
• Demonstrated ability to work effectively with culturally diverse populations and communities.

Examples of Competencies:

• Strong relationship-building and patient engagement skills. 
• Ability to work effectively with diverse populations and underserved communities. 
• Knowledge of community resources and social service programs. 
• Strong communication, listening, and motivational interviewing skills. 
• Ability to work independently in field-based environments. 
• Excellent organizational and documentation skills. 
• Commitment to patient-centered care and cultural humility. 
• Ability to manage multiple priorities while maintaining professionalism and compassion. 

Benefits: 

As a firm passionate about health care, we’re deeply committed to the health and wellness of our own team members. We offer comprehensive, affordable insurance plans for our team and their families, and a host of other unique benefits, such as a yearly stipend for wellness-related activities and a paid parental leave program. You can learn more about our benefits offerings here: https://copehealthsolutions.com/careers/why-cope-health-solutions/. 

About COPE Health Solutions
COPE Health Solutions is a national tech-enabled services firm powering success for health plans and for providers in risk arrangements. Our comprehensive NCQA certified population health management platform and highly experienced team brings deep expertise, experience, proven tools, and processes to improve financial performance and quality outcomes for all types of payers and providers. CHS de-risks the roadmap to advanced value-based payment and improves quality and financial performance for providers, health plans and self-insured employers. For more information, visit . 

To Apply: 

To apply for this position or for more information about COPE Health Solutions, visit us at https://copehealthsolutions.com/careers/open-positions/.

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