Community Health Worker Full Time

## Description The Community Health Worker (CHW) supports Hood Memorial Hospital’s quality improvement, population health, and community engagement initiatives with a primary focus on facilitating Chronic Disease Management (CDM), coordinating CDM-related outreach and follow-up, collecting and reviewing CDM data, and serving as the Substance Use Navigator (SUN) for the LA Bridge Program. This position connects patients to care, supports provider-directed care plans, identifies and addresses social drivers of health, coordinates referrals and closed-loop follow-up, and maintains accurate program documentation and reporting, including monthly MCIP data collection for submission. # Essential Duties & Responsibilities · Chronic Disease Management Facilitation · Coordinate outreach and follow-up for patients with chronic disease needs, missed or overdue appointments, post-discharge follow-up needs, barriers to care, or noncompliance with chronic disease management expectations. · Support patients in understanding provider instructions, diagnoses, medications, prevention strategies, and recommended follow-up, as directed by the provider or care team. · Assist patients with scheduling and attending appointments as needed to improve visit attendance compliance and continuity of care. · Provide one-on-one or group health education related to chronic disease, prevention, medication adherence, and self-management support. · Chronic Disease Management Data Collection, Review & Reporting · Collect, maintain, and review CDM-related data using the EHR, approved tracking tools, and assigned population health platforms. · Identify patients through EHR SDOH screening data, chronic disease management reports, emergency department utilization patterns, insurance gaps, and other approved data sources. · Track patient progress, outreach attempts, referrals, follow-up completion, and outcomes related to care plan goals and CDM workflows. · Participate in quality review, assurance follow-up, interdisciplinary case reviews, huddles, and QI activities to evaluate trends, barriers, opportunities, and interventions. · Contribute concise, timely data updates for program reporting, leadership review, grant reporting, and performance improvement activities. · Substance Use Navigator (SUN) / LA Bridge Program · Serve as the Emergency Department SUN and primary liaison for substance use navigation activities, including screening coordination, brief interventions, MOUD warm handoffs, naloxone education, and referral coordination. · Coordinate follow-up and closed-loop referrals for patients identified with substance use needs, behavioral health needs, or related social service barriers. · Maintain SUN-related documentation and tracking requirements in accordance with approved workflows, HIPAA expectations, and program requirements. · Collect monthly MCIP data elements assigned to the SUN/LA Bridge Program role and prepare data for submission through the designated reporting process. · Social Drivers of Health, Resource Navigation & Community Linkages · Conduct standardized SDOH screenings, document findings, and connect patients to appropriate internal and external resources. · Coordinate referrals and closed-loop follow-up for needs such as food, housing, transportation, Medicaid, Marketplace insurance options, financial assistance, behavioral health, and primary care access. · Maintain a current community resource/referral list and build relationships with local nonprofits, food banks, housing agencies, behavioral health providers, and social service coalitions. · Support CHNA review, activities, community health education, community events, and other initiatives that improve population health and access to care. · Care Coordination, Documentation & Compliance · Accurately document patient interactions, service encounters, referrals, follow-up activity, and outcomes in the EHR and/or approved tracking systems. · Apply appropriate Medicaid and Medicare reimb…