The Community Health Worker (CHW) serves as a trusted liaison between patients, the FQHC care team, and community-based organizations. The CHW screens patients for Health-Related Social Needs (HRSN), facilitates referrals to community and health resources, supports care coordination across the care continuum, and conducts community outreach to improve health outcomes, reduce avoidable utilization, and advance health equity. This role works closely with FHCSO's integrated care team—including physicians, nurse practitioners, behavioral health providers, and case managers—to address the social drivers of health and support value-based care goals.
• Conduct standardized Health-Related Social Needs (HRSN) screenings for all eligible FQHC patients, addressing food insecurity, housing instability, transportation barriers, utility needs, interpersonal safety, and nicotine use (including adolescents ages 13–17).
• Identify patients who may benefit from chronic disease management and prevention programs (e.g., Diabetes Prevention Program, weight management, tobacco cessation) aligned with FQHC quality measures and UDS reporting requirements.
• Utilize FQHC-approved screening tools and motivational interviewing techniques to assess patient strengths, goals, and barriers within a trauma-informed framework.
• Document all screenings and patient interactions in the FQHC's electronic health record (EHR) and designated data systems, consistent with HRSA/UDS documentation standards.
• Provide referrals to internal FQHC services (behavioral health, dental, pharmacy, enabling services) and external community-based organizations.
• Assist patients in navigating and enrolling in public benefit programs (e.g., Medicaid/SoonerCare, SNAP, Supplemental Nutrition programs, LIHEAP) and FQHC sliding-fee scale services.
• Conduct closed-loop referral follow-up to ensure successful connection to services and address barriers; document outcomes in the EHR.
• Support care transitions, medication adherence, follow-up appointment scheduling, and transportation coordination—with particular attention to patients with chronic conditions and high ED utilization.
• Collaborate with FQHC care managers, behavioral health consultants, social workers, nursing staff, and providers to support integrated, patient-centered care plans.
• Track referral outcomes and support quality improvement efforts in alignment with HRSA reporting requirements, including submission of required reports to the Oklahoma Primary Care Association (OPCA) or applicable oversight entities.
• Develop and maintain partnerships with community-based organizations, social service agencies, faith-based organizations, and local stakeholders to expand the FQHC's community presence and trust.
• Participate in and support community outreach initiatives to increase awareness of FQHC services—including sliding-fee scale options, enabling services, and telehealth—and to engage uninsured and underserved populations.
• Maintain and regularly update a community resource directory tailored to the FQHC's service area, including resources relevant to migrant/seasonal farmworkers, individuals experiencing homelessness, and other special populations as applicable.
• High school diploma or equivalent required; Associate's or Bachelor's degree in public health, social work, or related field preferred.
• Within the first year of employment, obtain Community Health Worker (CHW) certification by completing applicable training or after 1,000 working hours, whichever comes first.
• Experience working in community health, social services, or primary care/FQHC settings preferred.
• Strong knowledge of local community resources, social service systems, and public health programs.
• Excellent communication, interpersonal, and organizational skills.
• Ability to work effectively with diverse, underserved populations and demonstrate cultural humility.
• Experience with electronic health record systems (particularly in a primary care or FQHC environment).
• Bilingual or multilingual skills reflective of the community served (Spanish preferred).
• Familiarity with HRSA requirements, UDS reporting, and federally qualified health center operations.
• Experience working in rural or frontier healthcare settings.
Job details are sourced from the employer's original posting.
Open job postingAbout the company
A community health center providing comprehensive medical and dental services to underserved populations in southern Oklahoma.