Job Description

Job Title:                       Community Health Worker – Integrated

Reports To:                   Community Health Worker Supervisor

Job Summary:                     Integrated into clinical services alongside care teams, serving as an extension of the care team to address patient needs beyond the walls of the clinic. Provides basic health checks and screenings, care coordination, and follow-up under the guidance and recommendations of a clinical care team. Assists community members in enrolling in Marketplace and Affordable Care Act plans as well as in our Sliding Fee Discount Program. Works with clinical care team to address patient’s social determinants of health.


Qualifications and Requirements:

To perform this job successfully, an individual must be able to perform each essential job duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required. 


Essential Job Duties:

Provides basic health checks and screenings, care coordination, and follow-up

  • Integrated into clinical services alongside care teams, serving as an extension of the care team to address patient needs beyond the walls of the clinic.
  • Under the guidance of the clinical care team and quality department, facilitates closing of quality measure gaps.
  • Screens, documents, and reports back on patient’s social determinants of health.
  • Screens for diabetes, hypertension, and high cholesterol by performing glucose finger sticks, blood pressure screenings and others as assigned.
  • Screens for high BMI (Body Mass Index) and provides appropriate education and referrals.
  • Renews clinical skills checklist sign-off annually to ensure accurate collection of blood pressure, blood sugar, height, weight, BMI, neck and waist measurement, oxygen saturation metrics
  • Screens, documents, and reports back on patient’s social determinants of health.
  • Completes and documents all community health screenings accurately into NextGen Electronic Health Record and submits monthly reports.
  • Prepares and updates educational material on health care programs and services so that it is culturally appropriate.
  • Performs quality assurance testing on all equipment as directed.
  • Attends and participates in department-specific training and staff meetings.
  • Attends Community Health Worker conferences and other developmental/educational opportunities.
  • Assists patients with scheduling clinic appointments when in the community.

Performs clinical duties within scope while working on clinical care team  

  • Obtains and records patients vital signs according to protocol (blood pressure, blood sugar, height, weight, BMI, neck and waist measurement, oxygen saturation) prior to patient seeing provider
  • Fills out necessary paperwork for recording purposes, inputs vitals information into NextGen for provider review
  • Maintains patient confidentiality following HIPAA policies and procedures
  • Communicates in a professional and timely manner with patients and other members of the care team at all times
  • Assists clinical staff with determination of patient eligibility for certain services such as immunizations (based on age and CDC guidance)
  • Follows up on provider tasks assigned to CHW team, including contacting and scheduling patients following or preceding a provider visit




Provides short term care coordination and connection to resources and support for patients.

  • Works to reduce cultural and socio-economic barriers between patients and the care team, health center or other institutions.
  • Assists patients in accessing health related services, including obtaining a medical home, overcoming barriers to obtaining needed medical care and/or social services.
  • Based on social determinants of health screening and needs, facilitates patient access to community resources, including locating housing, food, clothing, education and life skills training.
  • Assists patients in utilizing community services including scheduling appointments with social service agencies and assisting with completion of applications for programs for which they may be eligible.
  • Follows up with both patients and providers regarding health/social service plans to ensure patients’ medical needs are met.
  • Travels to patient homes, community locations, various agencies and other outreach destinations.


Maintains Optimal Department Productivity

  • Proactively schedules patient appointments.
  • Confirms patient appointments as needed.
  • Checks in patients on location.
  • Works assigned early mornings, late evenings and weekends as required.
  • Work in remote areas of Cochise County as required.


Transcribe Accurate Patient Demographic Information into the Required Systems to Ensure Timely Reimbursement of Visits

  • Verifies medical insurance coverage and eligibility when applicable.
  • Verifies patient demographic information.
  • Deciphers the correct amount to charge self-pay, prompt pay or sliding fee discount program for patients.


Provides Excellent Customer Service

  • Provides and facilitates the completion of necessary patient forms.
  • Assists patients with presumptive applications for Sliding Fee Discount Program.
  • Takes and documents messages as appropriate.
  • Proactively greets, interacts with, and assists patients and staff in a professional manner.
  • Travels to any location as needed.


Required Education, Experience, Certificates & Licenses:

  • High School Diploma or GED.
  • Completion of 40-hour domestic violence awareness training required within 6 months after hire.
  • Completion of 40-hour sexual assault awareness training required within 6 months after hire.
  • Completion and certification for Pesticide Handler and Worker Safety Training required within 6 months of hire.
  • Any combination of education and/or experience that provides the necessary skills required may be considered.
  • Must maintain current CPR training certification.
  • Must be 21 years of age and possess a current Arizona driver's license to qualify for coverage under company insurance. Proof of Insurance may be required if requesting mileage reimbursement.
  • Annual Health-E-Arizona plus and Certified Application Counselor Certification renewals are required.
  • Valid Fingerprint Clearance Card.


Preferred Qualifications – Education, Experience, Certificates & Licenses:

  • A background in health or social services field is preferred.


Required Language Skills:

  • Ability to comprehend and compose instructions, correspondence and communications in English in both oral and written format.
  • Bilingual in English and Spanish may be required depending on work location.


Physical Requirements:

  • Ability to frequently move objects weighing up to 25 pounds.
  • Ability to traverse short distances indoors and outdoors between work sites.
  • Possess hand-eye coordination and manual dexterity necessary to constantly operate computer, telephone, and other office machinery.
  • Possess close visual acuity necessary to accurately record and view information on a computer monitor, handwritten and typed documents.
  • Ability to discern the nature of sounds at a normal spoken volume.
  • Possess hand-eye coordination and visual acuity necessary to frequently operate a motor vehicle in normal and adverse weather conditions.
  • Possess range of body motion and ability to exert enough force to assist in moving and lifting patients.


Other Required Knowledge, Skills, and Abilities:

  • Ability to add, subtract, multiply and divide in all measure, using whole numbers, common fractions and decimals.
  • Ability to gather data in an organized fashion from varied sources.
  • Ability to perform a variety of assignments requiring independent judgment.
  • Ability to deal with challenges involving several variables in routine situations.
  • Knowledge of health plans and community health centers preferred.
  • Knowledge of HIPAA rules and regulations.
  • Knowledge of Medicaid and Medicare programs preferred.
  • Computer literacy required.
  • Knowledge of Electronic Health Records preferred.
  • Basic knowledge of preventable diseases such as diabetes, hypertension, and obesity.
  • Knowledge and ability to work with special needs populations (homeless, veterans, low income housing residents, migrant and seasonal farmworkers).
  • Ability to work independently and in “nontraditional” work settings.
  • Ability to establish positive, supportive relationships with patients, providers and the community.
  • Knowledge and understanding of community resources and services.


Work Environment & Conditions:

  • Work is frequently performed both indoors and outdoors with exposure to outside weather conditions to include heat and cold, and humid, windy and dry conditions.
  • Work is occasionally performed in a health clinic setting with occasional exposure to communicable diseases, bodily fluids and hazardous chemicals.
  • Work is occasionally performed in community-based settings, including client’s homes.
  • Work is frequently performed in farm fields with chance for exposure to pesticides.
  • Work includes frequent driving in normal and adverse weather conditions over improved and rough road surfaces.
  • Work requires reliable transportation as position requires frequent travel and extended hours to include early mornings, evenings, holidays and weekends.