The Community Health Worker (CHW) partners with the primary care team to assist patients and their families to improve individual and community health.  Responsibilities include culturally appropriate team-based health promotion and education through direct services provided in OHSU clinics, outreach, and community engagement.

 

The Scappoose Clinic is a Rural Health Center with approximately 12,000 paneled patients where there are over 35,000 primary care visits provided in a year. Over 60% of the patient population is insured by either Medicaid or Medicare in a clinic that is centered in Columbia County where community resources are limited.

 

The Community Health Worker demonstrates strong verbal and written communication skills, is self-directed, and is skilled at developing relationships quickly.  The incumbent is efficient and effective in assessing and delivering direct patient care, has an in-depth knowledge of local community resources, is innovative, thinks creatively, and demonstrates flexibility.

 

This is a 3 year limited duration position

Direct Patient Services and Documentation

• Respond to care team referrals and patient self-referrals for care coordination, individual and family support, health promotion, and resource system navigation.
• Support individuals and families with complex biopsychosocial needs in coordinating care with external providers and serves as system navigator and point of contact.
• Assumes advocate role on patient’s behalf to ensure receipt of timely and appropriate services. 
• Assists patients in problem solving issues related to health care delivery, financial or social barriers.
• Assists patients in gaining access to community services.
• Collaborates with care teams to meet patient/family and program goals

Health Education, Prevention and Outreach

• Deliver trauma-informed and culturally appropriate health education to patients, community members, and healthcare providers. Topics may include system navigation, chronic disease self-management, nutrition, and practical life skills (e.g., budgeting, cooking).
• Design and implement community-based interventions and home visits to promote engagement and behavior change.
• Conduct outreach and screening to identify social determinants of health and coordinate responses accordingly.

Documentation

• Complete timely, accurate documentation in the electronic health record (EHR), including collaborative care plans, progress notes, outreach activity, and billing-related notes as applicable.
• Ensure services provided are documented to support quality improvement and data tracking.

Clinic Access and Engagement

• Support patients in scheduling, understanding care instructions, arranging transportation, accessing language services, and overcoming other logistical barriers.
• Serve as a patient advocate and liaison between the patient and care team to promote engagement and trust.

Care Team Meetings and Development

• Participate actively in care team huddles, case conferences, staff meetings, and team development opportunities.
• Offer the CHW perspective on patient needs and system improvements.
• Engage with patient advisory groups to strengthen community voice and bridge relational gaps in care.

Community Engagement

• Build and maintain effective relationships with community organizations and service providers.
• Facilitate referrals and collaborative efforts to address resource gaps and innovate service delivery.
• Participate in community needs assessments and the development of programs responsive to those needs.
• Collaborate with Patient/Consumer Advisory Councils to improve systems of care.

• High school diploma or equivalent.
• 2 years relevant work experience in mission-driven organization with one of those years being work experience with underserved populations with complex medical and social needs.  Preferred experience in community outreach services providing health information, advocacy, social support, and assistance engaging with the healthcare system.
• Certification as Traditional Healthcare Worker (THW) required.  Traditional Health Worker types include Doula, Peer Support Specialist (PSS), Peer Wellness Specialist (PWS), Personal Health Navigator (PHN) and Community Health Worker (CHW).  Type preference may be determined by service need.
• Fluency in written and spoken English. Must be able to communicate effectively verbally and in writing. Excellent telephone communication skills.
• Must possess a valid motor vehicle driver license in good standing and must be eligible to operate a motor vehicle owned by OHSU or other agency; or demonstrate the ability to access transportation to meet the requirements of the position.
• BLS/CPR certification within 6 weeks of hire. 

• Must be able to communicate effectively verbally and in writing.
• Excellent telephone communication skills.   
• Understanding of Social Determinants of Health and role of SDH in healthcare.
• Ability to work independently utilizing critical thinking, problem solving, and time management skills.
• Skill in developing and maintaining professional relationships quickly.
• Ability to plan and deliver interactive health education classes and presentations for a variety of groups.
• Demonstrated understanding of trauma informed and patient centered care or willingness to learn.
• Ability to interpret and follow policies and procedures.

• Demonstrated skill in community outreach, resource navigation, and patient advocacy.

• Familiarity with Epic or other electronic health record (EHR) systems.
• Experience facilitating health education classes or supporting group interventions.
• Knowledge of the Collaborative Care Model and integrated care practices.

• Frequent interruptions in an environment of frequent change and fluctuations.
• May be exposed to body fluids, tissue, possible radiation exposure, and infectious processes.
• Subject to computer work for several hours, as needed.
• Able to utilize office equipment including computer, smart-phone, and pager at workspace and in community.

• Requires a valid Oregon driver’s license, vehicle and the ability to drive up to 8 hours.

   

• Standing: On concrete, vinyl, or carpeting up to 4 hours per day and intermittently.

   

• Sitting: Chair or stool continuous up to 8 hours per day and intermittently.

   

• Changing Position: Intermittently, as needed.

   

• Walking: Intermittently up to 8 hours per day on concrete, vinyl, and carpeting.

   

• Bending: From the waist and knees, frequently throughout the day.

   

• Reaching/Handling: Fine manipulation, repetitive, gross motor requiring full

• ROM in upper extremities, including overhead reaching.

   

• Twisting: All ROM required, intermittent periods, throughout the day.

• Climbing: Staircase, intermittently throughout the day.

Oregon Health & Science University values a diverse and culturally competent workforce. We are proud of our commitment to being an equal opportunity, affirmative action organization that does not discriminate against applicants on the basis of any protected class status, including disability status and protected veteran status. Individuals with diverse backgrounds and those who promote diversity and a culture of inclusion are encouraged to apply. To request reasonable accommodation contact the Affirmative Action and Equal Opportunity Department at 503-494-5148 or aaeo@ohsu.edu.