Community Health Worker

About Us:

God’s Love We Deliver, a nonsectarian organization, is the New York metropolitan area’s leading provider of life-sustaining meals and nutrition counseling for people living with severe illnesses. Begun as an HIV/AIDS service organization, God’s Love provides for people living with more than 200 individual diagnoses. God’s Love cooks and home delivers the specific, nutritious meals a client’s severe illness and treatment so urgently require. Meals are individually tailored for each client by one of our Registered Dietitians, and all clients have access to unlimited nutrition counseling. God’s Love supports families by providing meals for the children and senior caregivers of our clients. All of our services are provided at no cost to our clients. 

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 the health-related social needs that impact the outcomes for those clients. This person is specifically responsible for supporting the team’s efforts in bridging the gap between healthcare providers, social services, and our clients. The CHW plays a critical role in improving health outcomes by providing education, promoting preventive care, connecting clients to community resources and services, advocacy, and supporting our clients, their families, caregivers, and community members.

This is a remote position that requires travel and flexibility throughout the Capitol Region. Your office will include community and healthcare spaces. You must be a Capitol Region resident. Home visits are a possibility. Your leadership and team will be in New York City. Must be a self-starter and comfortable reporting daily.

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.
• Other duties as assigned.

About You:

You are highly self-motivated and empathetic, with a strong desire to provide support to clients living with a serious illness. You are looking for a collaborative, team-oriented environment, and you are energized by providing education and resources to clients.

Qualifications:

• 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.