Community Health Worker (CHW)

Your Role

The Community Health Worker (CHW) at Evergreen Nephrology supports high-quality, patient-centered care by providing exceptional patient service, care coordination, and connection to community-based resources. This role serves as a trusted liaison between diverse, underserved, and vulnerable populations and the health and social service systems that support them, with a strong focus on building trust, engagement, and patient empowerment.

Working within an interdisciplinary care team including Nurse Practitioners, Nurse Care Managers, Care Coordinators, Dietitians, Pharmacists, Licensed Clinical Social Workers, Population Health Social Workers, and Psychiatrists, the CHW leverages Evergreen’s integrated technology platform to help patients access services aligned with their individual needs. The CHW also partners with clinical teams and leadership to support community outreach initiatives designed to promote, maintain, and improve the health and well-being of patients and their families.

You will take the lead on comprehensive care coordination with a focus on identifying and addressing Social Determinants of Health while partnering with the interdisciplinary care team. You will be an essential resource for patients, assisting them in navigating the healthcare system, accessing resources and support, and achieving better health outcomes.

To be successful in this role, you must hold an active Community Health Worker (CHW) certification. Bilingual proficiency in Spanish and English is strongly preferred to support effective engagement with diverse patient populations.

Role Responsibilities

Some responsibilities may vary based on specific patient programs; however, the primary duties of the Community Health Worker include:

• Patient Engagement & Outreach
  • Conduct telephonic and virtual outreach to patients identified with high social determinants of health (SDOH) needs.
  • Establish trust and serve as a primary point of contact for patients enrolled in the CHW program.
  • Build culturally competent relationships that promote engagement, encouragement, and patient empowerment.
• Care Coordination & Navigation
  • Serve as a liaison between patients, families, clinical teams, dialysis centers, and community-based service providers.
  • Facilitate seamless transitions of care across care settings to support comprehensive, patient-centered care.
  • Assist patients with enrollment in health and social services, including completing applications, paperwork, and required documentation.
  • Support clinical staff by coordinating care activities, identifying resources, and addressing barriers to care.
• Social Determinants of Health
  • Conduct comprehensive assessments to identify social, economic, cultural, and environmental factors impacting patient health.
  • Recommend gap closures and contribute SDOH findings to individualized care plans to improve quality and health outcomes.
  • Connect patients to appropriate resources, including housing assistance, transportation, food security, utilities, and community support programs.
• Resource Management & Follow-Up
  • Guide patients in understanding and accessing available health and social services within Evergreen Nephrology and external organizations.
  • Follow up on and track referrals and outcomes related to pharmacy services, durable medical equipment (DME), home care, and other supportive services.
  • Assist with identifying, scheduling, and coordinating transportation for medical and community appointments.
  • Build and maintain up-to-date resource inventories across service areas and multiple states.
• Member Advocacy & Support
  • Advocate for patients by identifying barriers to care, addressing inequities, and ensuring appropriate interventions and support are provided.
  • Support patients and families in navigating complex systems and overcoming challenges that impact care access and adherence.
  • Administer health screenings as appropriate and support preventive and supportive care initiatives.
• Documentation, Reporting & Compliance
  • Maintain accurate, timely, and compliant documentation of patient interactions, assessments, referrals, and care plan updates in accordance with organizational and regulatory requirements.
  • Identify situations requiring mandatory reporting and complete all required reporting in accordance with state and organizational guidelines.
• Education & Empowerment
  • Provide education and resources to patients and families to address stressors and barriers to care.
  • Empower patients to manage their health conditions by increasing understanding of available supports and promoting self-advocacy.
• Perform other duties consistent with the Community Health Worker role, as assigned.

Required Qualifications

• 3+ years of experience in health care coordination, community health work, or similar healthcare related field
• Credentialed Community Health Worker
• Experience with team-based approach to care
• Excellent working knowledge of community resources
• Exceptional ability to prioritize and task-switch to meet needs of patients and overall care team
• Self-directed and motivated to resolve issues professionally and creatively
• Strong communication and teaching skills
• Intermediate skills with MS Office Suite of products including Outlook and Teams
• Able to work effectively in a primarily remote environment:
  • Home internet must support a minimum download speed of 25 Mbps and upload speed of 10 Mbps. Cable, Fiber, or DSL connections hardwired to the internet device are recommended
  • Evergreen will provide remote employees with telephony applications and equipment to meet the business requirements for their role
  • Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information