Community Health Worker

Penn Medicine, University of Pennsylvania Health System; Philadelphia (Philadelphia County); On-site; USD 36,000 - 52,000; Full time

Job summary

Penn Medicine is seeking a Community Health Worker to work with high-risk patients, providing social support, health system navigation, and behavior change counseling. The role involves open-ended needs assessments, collaboration with a multidisciplinary team, and documenting patient interactions.

CHW training is required at hire. This autonomous position emphasizes delivering follow-up care, coordinating resources, and supporting patients through their health journeys in West and Southwest

Qualifications

• H.S. Diploma or GED is required.
• Comfortable with home visits and outreach.
• Familiar with West or Southwest Philadelphia area and knowledge of local resources.
• Prior experience as an outreach worker.

Responsibilities

• Manage a caseload of 50–100 patients per year and meet established care benchmarks.
• Meet patients in hospitals or primary care clinics and identify health goals; use motivational interviewing to plan actions.
• Make weekly contact via follow-up calls or home visits.
• Coordinate with clinical teams to share patient goals and medical information.
• Co-facilitate a weekly support group for patients.
• Create a directory of community resources in West and Southwest Philadelphia.
• Document each patient encounter in detail.

Skills

Outreach experience

Education

High School Diploma/GED

Job description

Description

Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.

Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines. Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?

Summary:

• Community Health Workers (CHWs) work one-on-one with high-risk patients to set and achieve health goals. Responsibilities include the identification and setting of health goals and follow-up provision of social support, health system navigation, community resource linkage and behavior change counseling. This is an autonomous position which requires a consistent drive for excellence, ability to make appropriate and timely decisions with minimal supervision, and effective problem‑solving skills. CHWs are responsible for thorough and accurate documentation and working collaboratively within a multidisciplinary patient care team. CHW training must be completed upon hire.

Responsibilities:

• Manage a caseload of 50-100 patients/year and achieve established benchmarks for patient care, including: Contacting 100% of patients each week Resolving at least 60% of patient goals Receiving a perfect satisfaction rating (10 of 10 in the Net Promoter Score) from at least 90% of patients Ensuring at least 60% of hospitalized patients attend post-hospital primary care follow‑up within two weeks of discharge Ensuring at least 55% of outpatients achieve the chronic disease management goal they set with their physician
• Meet patients in hospitals/ primary care clinics and conduct open‑ended needs assessment to understand broadly what patients’ goals are for their health. Use motivational interviewing to help patients create action plans for reaching their health goals. Provide a wide variety of support (including emotional support, referral to community based resources, social services, clinical services, etc.) based on CHW discretion and available resources. Examples include: Resolving social issues like homelessness, substance abuse and hunger Assisting patients with organizing their records, making follow‑up appointments, and ensuring their prescriptions are filled Coaching patients on how to get the most out of their doctor visits Helping patients fill out applications for Medical Assistance and SNAP (Supplemental Nutrition Assistance Program)
• Make weekly contact (follow‑up calls and/or home visits) to patients.
• Coordinate and communicate with clinical care teams to provide relevant information about patient’s goals, clinical emergencies, and patient concerns, and to obtain medical information needed to inform CHW’s work.
• Co‑facilitate a weekly support group for patients.
• Work with other CHWs and staff to create a directory of community resources (e.g. foodbanks, housing assistance programs, childcare resources, etc.) in West and Southwest Philadelphia.
• Document each patient encounter in detail.

Credentials:

• H.S. Diploma/GED (Required)
• Comfortable with home visits and outreach
• Familiar with West or Southwest Philadelphia area and good knowledge of the resources of these communities
• Prior experience as an outreach worker

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.

Live Your Life's Work

We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.