Community Health Worker II

Description
JOB SUMMARY: The Community Health Worker II provides comprehensive care coordination and complex social case management services for high-risk patients, including individuals experiencing homelessness. This role conducts proactive outreach, assesses Social Determinants of Health (SDOH), develops individualized care plans, manages ILOS program services, and connects patients to medical, behavioral health, housing, and community resources. The Community Health Worker II also serves as a SOAR Benefits Specialist, assisting eligible individuals with SSI/SSDI applications and related documentation. The position maintains accurate records in HMIS, EMR, and other required systems and collaborates closely with clinical providers, behavioral health teams, community organizations, and external partners to ensure integrated, patient-centered care and improved health outcomes.

DUTIES AND RESPONSIBILITIES:

Case Management Duties:
Conduct proactive outreach to high-risk patients and coordinate their care to ensure seamless navigation of health and social service systems.
The Community Health Worker II will report to the MLK facility, however travel between clinic and community-based locations is required to support patient outreach and program activities.
Develop personalized care plans based on assessments, addressing barriers to self-sufficiency and independence.
Make referrals and provide follow-up support to connect patients with needed resources and services.
Participate in quality improvement initiatives, supporting the clinical practice team with a focus on patient-centered care.
Protect HIPAA and maintain patient confidentiality.
Maintain respectful, courteous, and appropriate communication and interpersonal skills with all staff members, volunteers, and patients.
Support patient care activities by managing time effectively, utilizing resources appropriately, and exemplifying excellence in attention to detail.
Facilitate transportation services and support patients in overcoming barriers to accessing medical care and social services, including addressing logistical challenges, coordinating appointments, and assisting with application processes.
Conduct client interviews to gather comprehensive data on medical history, socioeconomic status, and program eligibility.
Evaluate and follow-up with patients to assess progress and hold them accountable for achieving goals.
Assesses social needs and provides individualized care plans that address social barriers

SOAR (SSI/SSDI Outreach, Access, and Recovery) Responsibilities:
Complete interviews with individuals to gather information for SSI/SSDI applications.
Gather medical records and other information to complete SSI/SSDI applications.
Write SOAR Medical Summary Reports for individual applications.
Accompany individuals to appointments at the Social Security Administration.
Coordinate visits to medical doctors, psychiatrists, and other specialists to obtain evidence for the application.

Administrative Duties:
Maintain accurate records of all patients and manage case data in the Homeless Management Information System (HMIS) and other program systems as needed.
Collects, analyzes, and reports KPI metrics, actionable insights to Community Health Program Supervisor to support strategic decision-making and continuous improvement.
Enter data into electronic medical records (EMR) systems and other tracking systems.
Handle calls from patients and community partners regarding patient needs.
Attend and actively participate in staff meetings.
Perform basic administrative duties, including answering telephones, greeting patients, updating, and filing records, completing forms, handling correspondence, and scheduling appointments.

Other Duties:
Promotes and demonstrates Hope values of: Gospel motivation, Prayer, Excellence, Stewardship, Patience, Thankfulness, Humility, Service, Dignity through Relationship and Hospitality and Joy
Always maintains the confidentiality of Hope Christian Health Center finances and patient-related information.
Complies with HIPAA and protects patient information.
The Community Health Worker II ensures compliance with all 19 Health Resources and Services Administration (HRSA) Health Center Program Requirements.
The Community Health Worker II is also expected to actively participate in and support quality improvement activities and the clinical practice team efforts emphasizing the importance of the individual patient and putting the patient’s needs first.
Other duties as assigned.
Requirements
Qualifications:
One year of experience in case management or related experience – required.

Education:
High School Diploma or equivalent – required
Community Health Worker II Certificate – preferred
State of NV Community Health Worker Certificate – required
SOAR Certification – required

KEY COMPETENCIES FOR SUCCESS:
Faith to believe that Hope is a ministry of God, exemplifying the love of Christ, and held and directed by the Holy Spirit.
Excellent organizational and time management skills, with the ability to prioritize tasks, manage multiple cases, meet deadlines, and maintain accurate documentation.
Strong critical thinking, problem-solving, and decision-making skills, with the ability to assess patient needs, identify barriers, and develop effective solutions and care plans.
Proficiency in technology and data management systems, including electronic medical records (EMR), Homeless Management Information System (HMIS), Microsoft Office applications, and other program-specific software.
Ability to operate general office equipment, including computers, calculators, copy/fax machines, telephones, and other office technology.
Excellent communication skills, both written and verbal, with the ability to effectively engage patients, families, community partners, and multidisciplinary care teams.
Strong interpersonal and team-building skills, with the ability to collaborate effectively with clinical providers, behavioral health professionals, community organizations, and external partners.
Demonstrated passion for community health care and serving vulnerable populations.
Proven ability to maintain integrity, professionalism, and confidentiality in a fast-paced and high-demand environment.
Proven ability to manage performance goals and support continuous quality improvement initiatives.
Ability to interact with people from diverse ethnic backgrounds, ages, lifestyles, and special populations with sensitivity, respect, and cultural humility.

TYPICAL PHYSICAL DEMANDS:
Occasional standing, walking, lifting, reaching, kneeling, bending, stooping, pushing, pulling, and lifting and/or moving up to 25 pounds. Frequent sitting. Manual dexterity. Good reading eyesight and vision for close work. Ability to communicate by speaking and hearing in person or on the phone. Ability to travel to various locations.