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About the Role

The Community Health Worker (CHW) supports the mission and goals of God’s Love We Deliver by liaising with potential clients who may benefit from the NYS 1115 Waiver and assisting with programs and initiatives addressing health-related social needs. This role bridges the gap between healthcare providers, social services, and clients, playing a critical role in improving health outcomes through education, preventive care promotion, community resource connection, and advocacy.

Responsibilities

Build relationships within the community to promote trust and understanding.
Conduct outreach activities to identify and engage individuals with unmet health and social needs.
Organize and participate in community events, health fairs, and educational workshops.
Advocate for individuals to ensure access to healthcare services and other community resources.
Empower individuals to take an active role in managing their health.
Assist individuals in navigating the healthcare system, including scheduling appointments and completing paperwork.
Conduct screenings to identify individual eligibility to receive services related to unmet health and social needs.
Assess an individual’s health-related social needs using standardized tools to determine social risk factors that impact the client's health.
Facilitate referrals to healthcare providers, social services, and community resources (e.g., housing, food assistance, childcare).
Develop an individualized Social Care Plan for each client that provides a longitudinal view of the client's needs, eligibility for services, and services to which clients have been referred.
Follow up with clients to ensure they receive the services and support needed, ensuring that there is a “closed loop” referral process.
Act as a direct point of contact for clients regarding ongoing health-related social needs and support clients with any additional needs identified through regular interactions and applicable follow-ups.
Maintain accurate and confidential records of interactions with clients, including referrals, outcomes, and follow-ups in electronic client record systems.
Document and report on community needs, trends, and barriers to accessing services.
Contribute to program evaluation and improvement through feedback and data sharing.
Serve as a liaison between individuals and healthcare providers to address cultural or language barriers.
Maintain an active caseload of clients and monitor clients’ progress through the screening, navigation, and completion of services for which the client is eligible to receive.
Promote inclusivity and respect for diverse backgrounds in all interactions.
Perform other duties as assigned.

Requirements

Bachelor’s degree with at least 1-2 years of fast-paced healthcare case management experience, preferably with a nonprofit organization.
Familiarity and experience with supporting the Social Care Network state initiative.
Familiarity with NYS community-based organizations and/or healthcare environments is a plus.
Strong written and oral communication skills, with demonstration of creating and delivering compelling education materials to various audiences.
Ability to multitask, including using multiple systems for client documentation.
Ability to learn and utilize several healthcare platforms daily.
Current knowledge of standards of care and clinical guidelines for patients with chronic illness.
Superior attention to detail.
Must be able to operate effectively as part of a team and independently.
Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint).
Bilingual in English/Spanish a plus.

Skills

Communication
Multitasking
Microsoft Office Suite

Location

Capitol Region (travel required)

Work Type

Remote
Travel required

Experience Level

1-2 years of healthcare case management experience

Education Level

Bachelor's degree

About the Company

God’s Love We Deliver is a nonsectarian organization and the leading provider of life-sustaining meals and nutrition counseling for people living with severe illnesses in the New York metropolitan area.
Originally an HIV/AIDS service organization, God’s Love now serves individuals with over 200 diagnoses.
The organization cooks and delivers specially prepared, nutritious meals tailored to each client's medical needs, with access to unlimited nutrition counseling.
Services are provided at no cost to clients and include meals for their children and senior caregivers.