POSITION DESCRIPTION
Position Title: Full Time
Community Health Worker: Practice-Based and Healthy and Resilient 100 Date: 09/2022 -Written
Amended: 01/2026
Reports To: Practice Manager
Department: Clinical Operations Type: Non-Exempt
POSITION PURPOSE:
The Community Health Worker (CHW) helps increase access to health services for vulnerable people who are usually underserved by the health care system, through outreach, education, and peer support. The CHW is responsible for promoting behavior changes, assisting with linkages to appropriate health care services, and assisting individuals with self-management of chronic conditions. This role offers a wide range of abilities learned via education, training, and experience that are frequently transferable throughout the company, enabling people to manage various duties and obligations associated with the needs of the organization.
QUALIFICATIONS:
- Must be 18 years of age or older.
- High school diploma or GED
- Active CHW Certification (OR Completion of MiCHWA CHW certification program and maintain CEUs)
- Willingness to participate in regular continuing education and professional development
- 2 years of CHW experience
- Medical assistant welcomed to apply
- Must be able to travel with use of a personal vehicle
- Must possess the ability to read and interpret documents
- Must possess the ability to write routine reports and correspondence
- Must possess the ability to speak effectively before individuals and families
- Must possess the ability to interact respectfully with diverse cultural and socio-economic populations
ESSENTIAL RESPONSIBILITIES AND DUTIES:
AS PLANNED BY THE PRIMARY CARE TEAM:
- Conducts outreach and prevention with education services, for individuals who have chronic conditions which benefit from care coordination and disease management.
- Facilitates Implementation of the patient’s care plan, explaining the plan and answering patient questions, and interpreting health information.
- Regularly reports observations to the primary care team to facilitate medical care improvement, health status improvement, and risk reduction.
- Assists clients in gaining access to health insurance and other community-based social services.
- Promotes patient adherence to the treatment plan through patient and family engagement.
- Conducts behavioral health follow up call and connects patients to recommended services.
- Documents each patient served and aspects of the encounter in the patient’s electronic medical record.
- Establish trusting relationships with patients and their families while providing support and encouragement.
- Work cooperatively with other staff in coordinating patient care and pursuing team-based approaches to care delivery.
- Provide patients with access to school resources and help with IEPs/OHIs as needed.
- Schedule patients for follow up appointments after ED/urgent care visits.
- Promote patient portal use and increase access to patients for better compliance and communication.
- Provides culturally and linguistically appropriate services and health education to clients.
- Maintain a professional disposition while working with a multidisciplinary health care team.
- Coordinate transportation for clients to/from appointments, including accompaniment as needed.
- Develop relationships with area social service agencies to build knowledge of the resources available to clients and to provide links to these services.
- Participate actively in regular supervisory and team meetings, training sessions, conferences, seminars, and independent study.
- Provide ongoing follow-up, motivational interviewing, and goal setting with patients/families.
- Follow up with clients regarding appointments, care plans, and health goals.
- Maintains confidentiality and follows HIPAA standards in safeguarding patient information.
Summary
The Practice-Based Community Health Worker (CHW) assists patients in achieving their desired state of wellness. The CHW engages with patients and families on behalf of the primary care/wellness-focused practice. The CHW is skilled in communication, facilitating learning, coaching health behaviors, developing personal health action plans, and identifying/ addressing barriers to wellness. The CHW is expected to understand mental illness and addiction, being willing and ready to engage with clients who struggle with these issues.
Healthy and Resilient 100 Lead (HARC)
- Lead project implementation for the duration of the Healthy 100 cohort research.
- Facilitate all initial appointments and education for Healthy 100.
- Coordinate all appointments for the Healthy 100 cohort in all support activities.
- Maintaining up to date knowledge of community resources, supplies, and schedules.
- Assist the team to ensure continuous quality improvement and accurate, timely reporting of required data and participate in quality improvement reviews.
- Assist with maintaining all data collection and reporting for Healthy 100.
- Ensure basic needs are addressed (i.e. food and other social service referrals for the programs.
- Assist with all patient follow-up and patient care activities.
Ruby Cole Community Kitchen
- Plan, coordinate and host monthly Community Kitchen events with organizations such as Priority Health, Michigan State University Extension, Blue Cross Complete, food banks, private chefs and community partners to identify the needs of the community involving healthy eating and lifestyle habits.
- Create posts and material highlighting the Ruby Cole Community Kitchen meals and workshops.
- Identify, cultivate, and strengthen relationships with new and existing community chefs and grocers.
- Ensure all aspects of programs abide by food safety rules and regulations.
- Support grant reporting with data collection and tracking.
- Help launch curated seasonal produce and pantry box giveaways to the community.
WORKING CONDITIONS:
- Must be able to work on a flexible schedule including evenings and weekends (per agency requirements).
- Able to complete duties under stress, deadlines, and while attending multiple duties simultaneously.
- Prolonged computer related exposure, as well as sitting and standing at workstations for long periods of time.
