Population Health CHW: Community Care Navigator

Nmpca; Santa Fe (NM); Presencial; USD 28.000 - 36.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Full benefits

PTO

Professional development

340B prescription access

Descripción de la vacante

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.

Formación

• 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.

Responsabilidades

• 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.

Conocimientos

Community resources

Social barriers

Trust building

Communication skills

Independent work

EHR proficiency

Documentation

Educación

NM Certified CHW

Herramientas

Athena EMR

Descripción del empleo

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.