Care Advocate, Care Delivery

Jobtailor; Albuquerque (NM); On-site; USD 38,000 - 58,000; Full time

Job summary

Jobtailor is seeking a Community Health Worker to support patients with complex needs in New Jersey. You will engage with clients, assess social determinants, and coordinate care across providers to improve outcomes.

The role requires strong communication, cultural competency, and the ability to navigate billing and CMS processes. A high school diploma and driver’s license are required; CHW training preferred.

Qualifications

• 3+ years of relevant community outreach, facilitation, or healthcare experience.
• CHW training or certification preferred; equivalent experience will be considered.
• Willing to complete CMS-mandated training and state requirements.
• Strong computer skills and ability to navigate web-based and app-based systems.
• Deep understanding of socio-economic and public health challenges in New Jersey.
• Excellent written and verbal communication skills with an outgoing personality.
• High school diploma/GED; college degree preferred.
• Valid driver’s license, reliable transportation, and flexible schedule for occasional after-hours work.
• Committed to a drug-free workplace and pre-employment testing.

Responsibilities

• Execute person-centered care plans for patients with serious, high-risk illnesses.
• Act as the link between the patient and the billing practitioner; support care coordination.
• Conduct person-centered assessments to understand social and cultural context and identify unmet needs.
• Assist patients navigating New Jersey healthcare landscape and teach self-advocacy.
• Support patient communication templates and coordinate with tech team for CMS updates.
• Refer patients to community resources and build partnerships with local New Jersey organizations.
• Use motivational interviewing to help manage stress and improve treatment adherence.
• Maintain logs and ensure documentation meets Medicare clinical and social integration standards.

Skills

Communication

Cultural competency

Care coordination

Motivational interviewing

Adaptability

Education

High school diploma/GED

College degree preferred

CHW certification/training

Tools

CMS software

Job description

Responsibilities

• Execute person-centered care plans for patients with serious, high-risk illnesses. Assist in monitoring and revising disease-specific plans, especially when frequent adjustments in medication or treatment regimens are required.
• Act as the link between the patient and the billing practitioner. Support care coordination by managing provider availability, rescheduling, and providing post-hospital discharge support.
• Conduct person-centered assessments to understand the patient’s social and cultural context. Identify unmet social needs—such as food insecurity or housing instability—that impact the management of their serious condition and develop specific action plans to address them.
• Assist patients and caregivers in navigating the New Jersey healthcare landscape. Teach self-advocacy skills to help patients communicate effectively with specialists and coordinate transportation or access to telehealth.
• Support patient communication templates and automation. Coordinate with the tech team to set up workflows, handle technical troubleshooting, and update patient charts in the Case Management System (CMS) with precision.
• Refer patients to supportive services and community-based resources. Establish and maintain partnerships with local New Jersey organizations to bring targeted resources (legal aid, food assistance, etc.) to our members' attention.
• Use motivational interviewing and capacity-building to help patients manage the stress of chronic illness. Provide tailored education to improve treatment adherence and offer emotional support to families and caregivers.
• Maintain detailed logs of all interactions, including the amount of time spent and specific activities performed. Ensure all documentation meets the standards required for Medicare clinical and social integration services.

Requirements

• Community Health Worker (CHW) training or certification preferred. Equivalent experience in community health, social services or a related field will be considered.
• Compliance: Be willing to complete and maintain all CMS-mandated training and state-applicable requirements, including competencies in interpersonal building, service coordination, and professional ethical conduct.
• Experience: Have 3+ years of relevant community outreach, facilitation, or healthcare experience. Experience navigating high-risk chronic conditions or complex care management is a major plus.
• Technical Savvy: Have strong computer skills and the ability to navigate web-based and app-based systems with ease.
• Cultural Competency: Possess a deep understanding of the socio-economic and public health challenges facing disenfranchised populations in New Jersey.
• Communication: Have excellent written and verbal communication skills, with an outgoing personality and the ability to motivate and influence different types of people.
• Logistics: Have a high school diploma/GED (college degree preferred). Must have a valid driver’s license, reliable transportation, and a flexible schedule for occasional work outside regular business hours.
• Commitment: Be committed to a drug-free workplace and ready for pre-employment substance abuse testing and background checks.

Core Competencies

Demonstrates expertise in executing person-centered care plans and navigating complex healthcare systems, with a strong focus on cultural competency and community resource coordination. Proficient in communication and motivational interviewing to support patients with chronic illnesses and their families.