Job Description

Position Purpose:

The role of the Social Services Community Health Worker (CHW) is to assist individuals, families, and internal teams who are impacted by Social Determinants of Health (SDOH) needs. The Social Services CHW engages patients, creates a trusting relationship, and provides care coordination and management to patients with SDOH needs who have high rates of utilization and/or severe psychosocial vulnerability. The Social Services CHW will make patient visits in the home, community, Emergency Department, hospital or other settings and works with the patient to set health goals and closely communicate with members of the patients care team. The Social Services CHW provides support and assists members in understanding the implications and complexities of their current situation and/or overall personal care.

Essential Duties and Primary Accountabilities

  • Provides face to face care coordination services to high risk patients that are impacted by Social Determinants of Health such as: food insecurity, financial resources, legal assistance, transportation, applying for disability, accessing services, application assistance, etc.
  • Provides care coordination and care management services to patients in the community, homes and health care settings that patients access.
  • Provides advocacy, patient education and support in accessing community-based and hospital-based programs.
  • Utilizes resources of public and private agencies and community organizations to meet the needs of patients and families.
  • Assists patients with organizing their records, making follow-up appointments, and filling their prescriptions.
  • Helps patients fill out applications, for example for Medical Assistance and SNAP (Supplemental Nutrition Assistance Program
  • Makes referrals to case managers, as appropriate, and/or refers patient's family to community support services and resources.
  • Schedules and completes initial assessment, develops a patient-centric plan of care and schedules follow-up within specified timeframes
  • Telephonic or face to face contact with high risk patients of all ages to conduct a Care Needs Screening
  • Evaluate Care Needs Screening responses and make appropriate referrals to internal care management programs or to external resources.
  • Records and monitors the participants' progress toward goals within specific timeframes
  • Collaborate with youth and family service agencies at the local, county and state level including but not limited to schools, special education services, DCFS, family court systems.
  • Works collaboratively with the members PCP and/or other key providers in planning and directing each patient's treatment program
  • Clearly documents all activities in the patient record
  • Provides concise and thorough documentation through psycho/social assessment and progress notes, including changes in medical psycho/social functioning, progression and attainment of goals, referrals to internal and external agencies, and contact/involvement with patient's family.
  • Demonstrates cultural sensitivity and respect for the patient


  • High school diploma required, Bachelor's degree preferred
  • BLS Certified (CPR/First Aid)

Years of Experience:

Required minimum 2 years of experience in behavioral health management and/or acute behavioral health care setting focusing on outpatient/inpatient utilization, case management and discharge planning

Work Related Experience:

  • Experience working with the needs of vulnerable populations who have chronic or complex psychosocial needs
  • Experience working with disadvantaged populations, preferred
  • Experience in a managed care environment and case management experience, preferred
  • Must be able to effectively communicate, present and explain complex material with patients, family members, case managers, treating physicians and community organizations
  • Must possess the interpersonal skills to engage children and adolescents of varying ages and families in helping relationships.
  • Must be able to cope with the pressure of time limitations while respecting the needs of the patient and the requirements of the organization/department.
  • Ability to take action in solving problems while exhibiting sound judgment and a realistic understanding of issues; able to use reason, even when dealing with emotionally charged topics.
  • Ability to remain open-minded and change opinions on the basis of information, perform a wide variety of tasks and change focus quickly as demands change, and manage transitions effectively from task to task.
  • Must possess a strong belief in an organizational culture that encourages valuing and best service excellence practices demonstrated through personal behavior and work ethic.
  • Ability to travel, including valid driver's license and auto liability insurance coverage according to company policy.
  • Must possess the ability to present and explain complex material to physicians and other providers and member populations in a professional manner.
  • Ability to work in several databases and to comply with established documentation requirements
  • Exceptional organizational skills; ability to multi-task and work independently and part of a team
  • Demonstrate ability to prioritize, multitask, and work in a rapidly changing environment with multiple demand

Application Instructions

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