Community Health Worker - Referral Coordination

HOPE Family Health Services; Westmoreland (TN); Hybrid; USD 19,000 - 28,000; Full time

Job summary

HOPE Family Health Services in Tennessee seeks a Community Health Worker to help patients access HOPE services and community resources. The CHW communicates with patients and care teams, identifies barriers to care, coordinates follow-ups, and documents services in the electronic health record.

Roles may focus on medical or behavioral health support, language access, referrals, outreach, and resource navigation.

Qualifications

• High school diploma or equivalent required.
• Experience in health care, behavioral health, patient service, community outreach, or resource navigation preferred.

Responsibilities

• Build respectful, trusting relationships with patients and families; communicate in a culturally responsive manner and support patient choice and self-advocacy.
• Contact patients by telephone, electronic message, or in person; respond to questions, relay approved information, identify needs, and route clinical concerns to licensed staff.
• Help patients understand appointments, care plans, referrals, tests, and next steps using information approved by the care team.
• Identify barriers to care including transportation, insurance, cost, language, housing, and connect patients with HOPE programs and resources; follow up as assigned.
• Coordinate with medical, behavioral health, pharmacy, and other teams and external partners to support continuity of care.
• Maintain timely, accurate records of contacts, referrals, services, and follow-up in the electronic health record and other approved systems.
• Participate in team meetings, training, quality improvement activities, and updates to resource information and workflows.

Skills

Communication skills

Customer service

Organization / multitasking

EHR software

Education

High school diploma or equivalent

Tools

EHR software

Office software

Job description

POSITION DESCRIPTION - COMMUNITY HEALTH WORKER

This position is assigned to Referral Coordination, assisting patients with scheduling referrals, coordinating with outside providers, and following up to support access to recommended services.

JOB SUMMARY

The Community Health Worker (CHW) helps patients access and navigate HOPE Family Health services and community resources. The CHW communicates with patients and care teams, identifies barriers to care, coordinates follow-up, and documents services accurately. Depending on the assignment, the CHW may focus on medical or behavioral health telephone support, language access, referrals, outreach, care coordination, or connecting patients with resources such as food, housing, financial assistance, and transportation. Each CHW performs duties within their assigned area, training, credentials, and HOPE policies. Individual CHWs are not expected to perform every duty listed in this position description.

PRIMARY DUTIES & RESPONSIBILITIES

• Build respectful, trusting relationships with patients and families; communicate in a culturally responsive manner and support patient choice and self-advocacy.
• Contact patients by telephone, electronic message, or in person as assigned; respond to questions, relay approved information, identify needs, and route clinical concerns promptly to the appropriate licensed staff or provider.
• Help patients understand appointments, care plans, referrals, tests, and next steps using information approved by the care team; reinforce education and instructions without independently diagnosing, treating, or giving clinical advice.
• Identify barriers to care, including transportation, insurance, cost, language, food, housing, and access to services; connect patients with HOPE programs and community resources and follow up on connections as assigned.
• Coordinate with medical, behavioral health, pharmacy, and other teams and external partners to support continuity of care and timely follow-up.
• Maintain timely, accurate records of contacts, referrals, services, and follow-up in the electronic health record and other approved systems; protect confidential information.
• Participate in team meetings, training, quality improvement activities, and updates to resource information and workflows.

DUTIES BASED ON ASSIGNMENT AND QUALIFICATIONS

• Telephone support: manage incoming and outgoing patient communications, route messages, relay provider-directed results or instructions, and support medical or behavioral health workflows. Clinical triage or assessment is performed only by staff whose credentials, role, training, and HOPE authorization permit it.
• Referral coordination: track referrals, gather and transmit information through approved channels, obtain required authorizations, coordinate specialty appointments, inform patients of status and next steps, and follow up on completion.
• Language access: provide bilingual navigation and, when separately qualified and authorized under HOPE policy, interpret spoken communication or translate written material. Arrange qualified language assistance when needed.
• Records and care coordination: process assigned records and correspondence, obtain or document appropriate releases, support discharge follow-up and external service coordination, and respond to authorized information requests.
• Community engagement: participate in outreach, health fairs, patient education, resource navigation, and other community-based activities when assigned.

INTERMITTENT DUTIES

Performs other duties as assigned by Team Leader to support departmental operations and organizational needs.

OFF-SITE WORK

Off-site work is not a requirement of this position.

With prior Team Leader approval, various job tasks may be completed remotely. These may include, but are not limited to: trainings, conferences, meetings, and daily activities that need to be completed by a deadline.

At times working off-site for this position can be completed at the home of the employee. Employees approved for off-site work must have a confidential, designated workspace to ensure privacy and productivity.

Off-site work classification and arrangements will be reviewed by the Team Leader at hire, during annual performance evaluations, and as needed throughout the year.

SKILLS/QUALIFICATIONS

High school diploma or equivalent required; relevant experience in health care, behavioral health, patient service, community outreach, or resource navigation preferred.

Ability to communicate clearly and respectfully with patients, colleagues, and community partners; organize competing tasks and use sound judgment about when to elevate concerns.

Ability to use electronic health records and standard office software, or to learn them with training; knowledge of local resources and barriers to care preferred.

Additional language proficiency, interpreter qualifications, professional credentials, and Basic Life Support certification may be required for specific assignments. Any cli