Community Health Worker - Population Health

Nmpca; Santa Fe (NM); On-site; USD 28,000 - 36,000; Full time

Benefits offered by this job

Full benefits

PTO

Professional development

340B prescription access

Job summary

Southwest Care Center in Santa Fe, NM is seeking a full-time Population Health focused Community Health Worker to connect patients to care and address barriers in a Federally Qualified Health Center setting.

Responsibilities include outreach, care coordination, SDOH support, health education, documentation, and ongoing quality improvement participation. NM CHW experience preferred; Athena EMR is a plus.

Qualifications

• Knowledge of community resources and social service systems.
• Understanding of barriers impacting underserved populations.
• Ability to build trust with diverse patient populations.
• Strong communication, motivational interviewing, and problem-solving skills.
• Ability to work independently while collaborating within an interdisciplinary team.
• Basic proficiency with EHR systems, Microsoft Office, and population health tools.
• Ability to maintain accurate and timely documentation.

Responsibilities

• Conduct outreach to patients identified through population health reports, registries, provider referrals, and care management programs.
• Coordinate appointments with primary care, behavioral health, dental, specialty care, pharmacy, and community-based services.
• Screen patients for social needs such as food insecurity, housing instability, transportation barriers, utility assistance, and financial hardship.
• Provide culturally appropriate health education regarding chronic disease management, preventive care, medication adherence, and healthy lifestyle choices.
• Document patient interactions, outreach attempts, referrals, and outcomes in the EHR.
• Participate in interdisciplinary care team meetings and case reviews; assist with implementing patient-centered care plans.
• Represent the organization at community events, health fairs, and outreach activities.
• Participate in departmental quality improvement initiatives and maintain knowledge of standards.

Skills

Community resources

Social barriers

Trust building

Communication skills

Independent work

EHR proficiency

Documentation

Education

NM Certified CHW

Tools

Athena EMR

Job description

Southwest Care Center employees can answer yes to these 3 questions:

Do you want to make a difference? Do you believe everyone is entitled to quality healthcare? Do you desire to serve the underserved in your community?

For over 25 years, Southwest Care Center has been providing exceptional healthcare to the communities of Santa Fe and Albuquerque, NM. We are a non-profit, FQHC-LAL providing medical, behavioral health, case management, community outreach, diabetes education, and pharmacy services. We are proud to offer gender equity medicine, syringe exchange, and HIV/HEPC testing and services within our communities.

Southwest Care Center is currently seeking a full-time Population Health focused Community Health Worker in Santa Fe, NM

For a Community Health Worker (CHW) in the Population Health Department of a Federally Qualified Health Center Look‑Alike (FQHC‑LAL), the essential duties typically focus on connecting patients to care, addressing barriers, supporting quality initiatives, and improving health outcomes for targeted populations.

Practice Highlights:

Patient Outreach and Engagement

• Conduct outreach to patients identified through population health reports, registries, provider referrals, and care management programs.
• Contact patients by phone, text, mail, or in person to facilitate engagement in care.
• Re‑engage patients who are overdue for preventive services, chronic disease management visits, immunizations, or follow‑up appointments.
• Assist with locating and reconnecting patients who have become lost to care.

Care Coordination and Navigation

• Assist patients in navigating healthcare services and understanding their care plans.
• Coordinate appointments with primary care, behavioral health, dental, specialty care, pharmacy, and community-based services.
• Support transitions of care following emergency department visits, hospitalizations, or specialty referrals.
• Facilitate communication between patients and members of the care team.

Social Determinants of Health (SDOH) Support

• Screen patients for social needs such as food insecurity, housing instability, transportation barriers, utility assistance, and financial hardship.
• Connect patients with community resources and social service agencies.
• Assist patients with completing applications for benefits and support programs when appropriate.
• Follow up on referrals to ensure needs have been addressed.
• Population Health Initiatives
• Support population health campaigns focused on preventive screenings, immunizations, chronic disease management, and quality measures.
• Assist with outreach efforts related to UDS measures, PCMH initiatives, and value‑based care programs.
• Participate in care gap closure activities for targeted patient populations.
• Maintain patient registries and work queues as assigned.

Health Education and Coaching

• Provide culturally appropriate health education regarding chronic disease management, preventive care, medication adherence, and healthy lifestyle choices.
• Reinforce provider recommendations and care plan goals.
• Encourage patient self‑management and activation.
• Promote health literacy and understanding of available healthcare services.
• Documentation and Data Collection
• Document patient interactions, outreach attempts, referrals, and outcomes in the electronic health record (EHR).
• Maintain accurate records of community resource referrals and follow-up activities.
• Assist with data collection and reporting requirements related to quality improvement initiatives.
• Ensure documentation complies with organizational policies and regulatory requirements.

Care Plan Support

• Participate in interdisciplinary care team meetings and case reviews.
• Assist with implementing patient‑centered care plans developed by licensed clinical staff.
• Conduct follow‑up contacts to assess progress toward care plan goals.
• Identify and communicate barriers to successful care plan completion.
• Community Outreach
• Represent the organization at community events, health fairs, and outreach activities.
• Develop and maintain relationships with community organizations and resource partners.
• Promote available health center services within the community.
• Assist with enrollment and retention efforts for vulnerable populations.
• Quality Improvement and Compliance
• Participate in departmental quality improvement initiatives.
• Maintain knowledge of FQHC, HRSA, PCMH, and organizational standards.
• Complete required trainings and competency assessments.
• Adhere to patient confidentiality and HIPAA requirements.

Typical Knowledge, Skills, and Abilities

• Knowledge of community resources and social service systems.
• Understanding of barriers impacting underserved populations.
• Ability to build trust and rapport with diverse patient populations.
• Strong communication, motivational interviewing, and problem‑solving skills.
• Ability to work independently while collaborating within an interdisciplinary team.
• Basic proficiency with EHR systems, Microsoft Office, and population health tools.
• Ability to maintain accurate and timely documentation.

Position Highlights:

• Competitive pay
• Great work/life balance with generous time off plans
• CME/Professional development reimbursement with additional time off
• Tuition reimbursement
• Full benefits package including medical, dental, vision, 401k, paid time off, professional development programs, and 340B prescription access with substantial employer contribution

Candidate Highlights:

• 2+ years of experience preferred
• NM Certified Community Health Worker preferred
• Athena EMR experience highly desired
• Team collaborator and patient advocate

Living & Working in New Mexico:

• Rich cultural and historical diversity.

• 310 daysof sunshine, combined with a mild, dry climate and four distinct seasons! You'll forget what humidity is when you live here.

• Unlimited year-round outdoor opportunities including hiking, rock-climbing, rafting, motorized sports, and even skiing. Yes, we have really big ski mountains in and around the deserts of New Mexico!

• Diverse and inclusive communities with amazingly kind people from all walks of life.

• Gorgeous landscapes that include desert and majestic mountains. New Mexico has to be to be seen to believe.

• Continuous festivals, concerts, and events including the internationally known Balloon Fiesta of Albuquerque.

• International airport providing low-cost, quick access in-country and out.

• Big city amenities found in Albuquerque with easy access from Santa Fe (50 min). Many of our employees commute between these cities. Both cities are connected by the NM rail system for those looking for a relaxing commute with a breath-taking view.

• Great schools and family friendly communities.

• And let's not forget about New Mexican cuisine- it is some of the best food in the country. Will you have red or green?

Southwest Care Center is an equal opportunity employer. We offer equal employment opportunities to employees and applicants without regard to race, color, religion, sex, age,national origin, disability status, protected veteran status, sexual orientation, gender identity, or any other characteristic protected by federal or state law.

Job Details:

Location:

NM Santa Fe - Admin Galisteo

Worker Type:

EmployeeRegular

Scheduled Weekly Hours:

40