Telephonic Community Health Navigator

Geisinger; Danville (PA); On-site; USD 36,000 - 54,000; Full time

Benefits offered by this job

Healthcare benefits from day one

Vision, dental and domestic partners

Job summary

Geisinger is seeking a Certified Community Health Worker (CCHW) for the Social Needs Resource Hub in Pennsylvania. The role focuses on telephonic outreach, collaboration with care teams and community organizations, and connecting patients to resources addressing social determinants of health.

You will document outreach in the EMR, participate in team-based care, and support quality improvement with follow-up to ensure successful linkage to services.

Qualifications

• High school diploma or GED required.
• Minimum of 1 year related work experience required.
• Certified Community Health Worker (CCHW) – Pennsylvania Certification Board required.

Responsibilities

• Orients and trains new Community Health Workers.
• Assesses patient needs and coordinates with care teams and community resources.
• Facilitates referrals to transportation, food, housing, and other social services.
• Documents outreach, referrals, and outcomes accurately in Geisinger’s EMR.
• Provides follow-up to confirm linkage and address barriers to care.
• Engages patients by phone and in-person as needed to support treatment plans.
• Participates in multidisciplinary team conferences to maximize the treatment plan.

Education

High School Diploma or GED

Job description

Job Summary

The Certified Community Health Worker (CCHW) within the Social Needs Resource Hub (SNRH) provides patient-centered outreach, primarily through telephonic engagement, to individuals with identified social needs. Working within a team-based model, the CCHW collaborates with healthcare teams, community-based organizations (CBOs), and hub colleagues to assess needs and coordinate appropriate support. The CCHW utilizes motivational interviewing and problem-solving techniques to educate patients and connect them to community resources that address social determinants of health, including transportation, food insecurity, housing, financial strain, and utilities. This role includes facilitating referrals and partnering with CBOs through the Neighborly platform to ensure timely and effective linkage to services. The CCHW conducts follow-up outreach to confirm successful connections and address barriers, supporting a shared team workflow and accountability model. Accurate and timely documentation within Geisinger’s electronic medical record (EMR) is required to capture outreach efforts, referrals, and outcomes, supporting reporting, quality improvement, and program evaluation

Job Summary

The Certified Community Health Worker (CCHW) within the Social Needs Resource Hub (SNRH) provides patient-centered outreach, primarily through telephonic engagement, to individuals with identified social needs. Working within a team-based model, the CCHW collaborates with healthcare teams, community-based organizations (CBOs), and hub colleagues to assess needs and coordinate appropriate support. The CCHW utilizes motivational interviewing and problem-solving techniques to educate patients and connect them to community resources that address social determinants of health, including transportation, food insecurity, housing, financial strain, and utilities. This role includes facilitating referrals and partnering with CBOs through the Neighborly platform to ensure timely and effective linkage to services. The CCHW conducts follow-up outreach to confirm successful connections and address barriers, supporting a shared team workflow and accountability model. Accurate and timely documentation within Geisinger’s electronic medical record (EMR) is required to capture outreach efforts, referrals, and outcomes, supporting reporting, quality improvement, and program evaluation

Job Duties

• Orients and assesses new Community Health Workers.
• Provides regular assessment of the level of proficiency demonstrated by staff during the orientation period in order to support decisions to move staff along in training or refocus until proficiency is met.
• Assists in the identification and outreach of medically complex patients.
• Collaborates with the multidisciplinary team in the development and implementation of the care plan.
• Engages patients by way of phone call, home visit, hospital visit, and accompanying patients to Providers appointments as needed.
• Completes vital signs.
• Identifies gaps in care and connects members with resources.
• Facilitates telemedicine visits with members and providers.
• Performs disease specific education.
• Conducts Medication Review to ensure medication adherence.
• Conducts safety evaluations in patients home.
• Facilitates adherence to treatment plan by early identification and resolution of gaps in care.
• Communicates all concerns to clinical team and manager as necessary, seeking support and guidance proactively.
• Participates in multidisciplinary team conference in order to maximize the treatment plan.
• Provides reinforcement of the treatment plan under the direction of the Case Manager and Licensed Social Worker and is available for consultation and case review as needed.
  
  

Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.

Position Details

Education

High School Diploma or Equivalent (GED)- (Required)

Experience

Minimum of 1 year-Related work experience (Required)

Certification(s) and License(s)

Certified Community Health Worker (CCHW) - Pennsylvania Certification Board

OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation. SAFETY: We provide a safe environment for our patients and members and the Geisinger family We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. We know that a diverse workforce with unique experiences and backgrounds makes our team stronger. Our patients, members and community come from a wide variety of backgrounds, and it takes a diverse workforce to make better health easier for all. We are proud to be an affirmative action, equal opportunity employer and all qualified applicants will receive consideration for employment regardless to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran.