General Definition and Scope of Job

The Community Health Worker will be an integral member of the care team. The CHW will work closely with care managers, other care management team members, health care providers, social services and behavioral health providers and community partners. The CHW will serve as a liaison/link/intermediary between the care team and the community to facilitate access to services, reduce barriers, increase cultural competency and actively build individual and community capacity.

Core Responsibilities

• Conducts patient outreach and engagement activities focusing on school population including face to face, mail, electronic and phone contact.
• Conducts outreach and engagement activities that support patient continuity of care, including re-engaging patients in care if they miss appointments and/or do not follow up on treatment.
• Supports the development and execution of patients’ care plans, including assisting patients in understanding care plans and instructions and tailoring communications to appropriate health literacy levels.
• Promotes patient treatment adherence through assisting patients in making changes to daily routines, identifies barriers and assisting patients with developing strategies to address barriers.
• Provides informal counseling, behavior change support and assistance with goal setting and action planning.
• Assists patients with navigating health care and social service systems including arranging for transportation and scheduling patient appointments.
• Assists care managers in monitoring and evaluating patients’ needs, including for prevention, wellness, medical, specialist, and behavioral health treatment, care transition and social and community service needs.
• Identifies available community-based resources and actively manages appropriate referrals, access, engagement, follow-up and coordination of services.
• Coordinates patients’ access to individual and family supports and resources.
• Provides support for chronic disease self-management to patients and their families.
• Coordinates access to the basic determinants of health (e.g. food, clothing, shelter, utilities).


• Collects and reports on data for program evaluation.
• Provides information on patients to care team members.
• Documents in medical record patient information and interventions.
• Manages calls, inquires and appointment schedules to ensure quality and timely patient customer service
• Collects mandatory patient information to ensure accurate demographic entries.
• Obtains needed insurance referral and/or authorization for services.
• Verifies patients’ insurance eligibility and benefits.
• Other duties as assigned.

Minimum Skills, Experience and Educational Requirements


• High School diploma or GED required. Associate’s degree preferred in Human Services field.
• 1-3 years related work experience preferred.
• Minimum 2 years of related work experience without a related Associate’s degree
• Excellent verbal and written communication skills.
• Experience with computer systems required, including web based applications and some Microsoft Office applications which may include Outlook, Word, Excel, PowerPoint or Access.

Critical Demands of the Job

• Bi-lingual capacity preferred for outreach to underserved and hard to reach populations, including Chinese, Portuguese and Arabic speakers.
• Manage multiple requests and prioritize appropriately.
• Must be able to consistently demonstrate integrity, compassion and respect, diversity and teamwork, excellence and innovation in work activities and interactions.
• Ability to function in a fast paced setting with a variety of patients and staff.
• Attention to details and prompt follow up.
• Includes walking and standing for long periods of time, sitting for short periods of time, hand dexterity, clear hearing and speaking ability. Must be able to lift a minimum of 1/3 of their body weight.
• Excellent organizational and interpersonal skills.

Required Certifications and Licenses

• Community Health Worker Certification is required, and certification training will be provided for successful candidate if not already acquired.
• Valid driver’s license, frequent local and occasional state-wide travel.

Working Conditions

• Works in well-lighted environment with comfortable surroundings.
• Stressful at times due to competing demands, including attention to multiple patients and staff.
• Will comply with all applicable laws, and will cooperate with the Manet Community Health Center compliance program rules and regulations.

Required Availability

May be required to work evenings, holidays or weekends.