Job Description

Position Objective:

The CHW will provide patient-centered outreach, education, care coordination, and navigation services to patients being discharged from Luminis Health hospitals. The CHW serves as a trusted community liaison who builds rapport, assesses social determinants of health and barriers to successful transition, supports medication and appointment adherence, connects patients to community and social services, and reinforces discharge instructions and self-management plans. This role requires strong communication skills, cultural competency, problem-solving ability, and an ability to work collaboratively with nurses, physicians, social workers, case managers, and external community partners.

Essential Job Duties:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions:

Conduct virtual outreach to assigned patients post discharge to introduce the transitional care program and obtain consent for post-discharge support. Complete outreach to 100% of assigned patients within 24-48 hours of discharge Perform standardized assessments focused on social determinants of health (housing, food security, transportation, utilities, caregiving support), health literacy, medication access, and home safety. Document assessment findings and contribute actionable items to the patient's post-discharge care plan within 24 hours of assessment. Work with the provider to assist patients in understanding discharge instructions, medication regimens, and follow-up appointments using teach-back methods; track and report patient comprehension rates. Coordinate and schedule follow-up primary care and specialist appointments, diagnostic testing, home health, durable medical equipment (DME), and community-based resources as indicated. Connect patients to community resources--food assistance, housing support, utility assistance, behavioral health services, chronic disease self-management programs, community-based organizations--and initiate referrals within 48-72 hours of need identification. Maintain an up-to-date resource directory and track referral outcomes; aim to successfully link patients to external services within 30 days. Conduct structured follow-up (phone calls, telehealth, or home visits per program guidelines) within 48-72 hours post-discharge and additional contacts as determined by risk stratification (e.g., 7-day and 30-day check-ins). Monitor for signs of clinical deterioration, social instability, or barriers that might precipitate readmission and escalate to clinical staff immediately when indicated Develop and maintain partnerships with community-based organizations, home health agencies, and primary care practices to ensure warm handoffs and continuity of care.

Required Education/ Experience/ License and Certifications:

High school diploma or GED required; Certified Community Health Worker (CHW) credential or willing to obtain within program-specified timeframe Minimum 2 years of experience in community health, care coordination, patient navigation, or related frontline health/social services role (hospital discharge or transitional care experience preferred). Demonstrated experience working with diverse, underserved, and medically complex patient populations. Strong verbal and written communication skills; ability to document concisely and accurately in EPIC Basic health literacy coaching skills and ability to use teach-back methodology.. Demonstrated problem-solving, time management, and organizational skills; capacity to manage a caseload and prioritize follow-up tasks. Ability to perform home visits and local travel as needed; valid driver's license and reliable transportation preferred if role requires travel.
Strong interpersonal skills and ability to build trust with patients, families, and clinical teams.

Working Conditions, Equipment, Physical Demands:

There is a reasonable expectation that employees in this position will be exposed to blood-borne pathogens.

Physical Demands -

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position.


Pay Range
$19--$26 USD

Luminis Health Benefits Overview:

Medical, Dental, and Vision Insurance Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year) Paid Time Off Tuition Assistance Benefits Employee Referral Bonus Program Paid Holidays, Disability, and Life/AD&D for full-time employees Wellness Programs Employee Assistance Programs and more Benefit offerings based on employment status

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