Senior Community Health Navigator for SDoH & Care Coordination

CHRISTUS Health; Irving (TX); On-site; USD 52,000 - 72,000; Full time

Job summary

CHRISTUS Health is seeking a Senior Community Health Worker to lead field-based and telephonic interventions addressing Social Determinants of Health within value-based contracts. You will mentor CHWs, support program planning, and contribute to performance analytics and health equity initiatives across the region.

The role involves advanced outreach, care navigation, and collaboration with care teams to reduce disparities and improve outcomes for attributed populations.

Qualifications

• High school diploma or equivalent required.
• Associate or bachelor’s degree in Public Health, Social Work, Health Education, or health related field preferred.
• Must have skills in trauma-informed care, health coaching, and culturally competent engagement.
• Minimum of 3 years CHW experience, including direct patient navigation or case management for underserved populations.
• Experience working within value-based care, managed care, or VALUE BASED CARE settings is strongly preferred.
• Demonstrated ability to mentor, coach, or lead peers in a professional or community-based setting.
• Strong technical proficiency with care management systems, Microsoft Office, and health information systems (e.g., Epic).
• Deep understanding of SDoH domains and available local/regional resources.

Responsibilities

• Build trusting relationships with Value Based Care patients and families to identify and address SDoH barriers.
• Assist patients in setting personal health goals and navigating care plans.
• Provide hands-on support in accessing healthcare services, social services, transportation, housing, and other resources.
• Encourage patient self-management, including appointment attendance and education participation.
• Advocate for patients and communicate needs to care team and community partners.
• Conduct outreach, needs assessments, and care navigation for high-risk populations.
• Address complex SDoH cases involving housing instability, food insecurity, mental health, or transportation barriers.
• Develop person-centered care plans and reinforce self-efficacy through coaching.
• Lead group education sessions or community events aligned with population health goals.
• Mentor CHWs, support onboarding, training, and shadowing.
• Coach CHWs on engagement strategies, resource navigation, and documentation.
• Collaborate on workflows, toolkits, and quality improvement with Care Management leadership.
• Support community health strategies to reduce disparities and improve HEDIS/STARS measures.
• Participate in outreach campaigns, health equity pilots, and process-improvement initiatives.
• Work with care coordinators, nurse navigators, social workers, and providers on interdisciplinary care planning.
• Document encounters and follow-up actions in Epic EHR or other platforms.
• Assist with metric development and reporting for grant-funded initiatives.

Skills

Trauma-informed care

Health coaching

Culturally competent engagement

Education

High school diploma or equivalent

Associate or bachelor’s degree in Public Health, Social Work, Health Education, or health related field

Tools

Epic EHR

Care management systems

Microsoft Office

Job description

CHRISTUS Health is seeking a Senior Community Health Worker to lead field-based and telephonic interventions addressing Social Determinants of Health within value-based contracts. You will mentor CHWs, support program planning, and contribute to performance analytics and health equity initiatives across the region.

The role involves advanced outreach, care navigation, and collaboration with care teams to reduce disparities and improve outcomes for attributed populations.