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14 Sep 2023

Full-Time Community Health Worker (SDoH) – Must live in Allegany or Garrett County, MD

HRMCMI1201 – Posted by HRMCMI1201 Frostburg, Maryland, United States

Job Description


Summary/Position Objectives:

This position will be part of the Maryland Physicians Care (MPC) Social Determinants of Health (SDoH) team. This team will work directly with MPC members to address social barriers to optimal health. In conjunction with SDoH team, works closely with medical providers, primary care teams, and social services agencies to provide short term care coordination and connection to resources and support to program clients to improve their health and general well-being through education and provision of coordination of care and services. Works in both clinical and community-based settings, including client’s homes.



Essential Functions:

  • Conducts intake interviews with clients and completes the Social Determinants of Health (SDOH) assessment
  • Assists clients in their homes, community, or clinic setting.  Communicates to clients/patients the purposes of the program and the impact it may have on their well-being.  Helps patients identify socio-economic issues that affect their overall health and develop health/social management plans and goals.
  • Assist clients in accessing social services to address identified barriers to care.
  • Partners with community organizations, governmental agencies, and local resources to develop productive relationships and programs.
  • Documents all client encounters and contracts made on behalf of clients; completes and submits monthly reports; maintains comprehensive electronic client files, which include client notes, release of information, assessments and other medical documents acquired on behalf of the client.  Documents activities, service plans, and outcomes achieved by client in an effective manner.
  • Assists patient in understanding care plans and instructions.  Motivates patients/clients to be active and engaged participants in their health and overall well-being.
  • Develops trusting relationship with target members by providing support and advocacy to help achieve health goals.
  • Assists clients in accessing health related services, including but not limited to obtaining a medical home, providing instruction on appropriate use of the medical home, overcoming barriers to obtaining needed medical care and/or social services.
  • Provides support and advocacy during medical visits or when necessary to assure client’s medical needs and referrals required are being conveyed.  Follows up with both clients and providers regarding health/social services.
  • Continuously expands knowledge and understanding of community resources and services.  Facilitates client access to community resources, including locating housing, food, clothing, prenatal classes, parenting, and providers to each life skills, and relevant mental health services.
  • Assists clients in utilizing community services, including scheduling appointments with social services agencies, and assisting with completion of applications for programs for which they may be eligible.
  • Facilitates communication and coordinate services between providers and the clients/patients.  Coordinates and monitors services, including comprehensive tracking of clients’ compliance in relation to care plan objectives.
  • Works collaboratively and effectively within a team.  Establishes positive, supportive relationships with participants and provides feedback to other members of the team.  Builds and maintains positive working relationships with clients, providers, nurse case managers, agency representatives, and office staff, from diverse cultural and socio-economic backgrounds.  Works to reduce cultural and socio-economic barriers between clients and institutions.

Secondary Functions:

  • Observe confidentiality of member records in accordance with MPC policies and procedures.
  • Works in a collaborative manner with peers, supervisors and/or subordinates.
  • Must maintain regular and acceptable attendance at such level as is determined in the employer’s sole discretion.
  • Must be available and willing to work such days and hours as the employer determines are necessary or desirable to meet its business needs.
  • Must be available and willing to travel 50-75% to onsite locations such as client homes or community-based organizations/health facilities and with such frequency as the employer determines is necessary or desirable to meet its business needs. Possession of a valid Maryland State Driver’s License is a requirement for this position.
  • Work requires incumbent who provides such services in patient care or clinical areas are required to be fully vaccinated “proof of vaccination” required for this position.
  • Performs miscellaneous job-related duties as required.


Knowledge and Skills:

  • Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
  • Knowledge of community agencies and resources.
  • Working knowledge of multi-system outreach programs related to health care delivery, clinical education, and health-related services.
  • Ability to plan, implement, and evaluate individual client care plans.
  • Knowledge of transportation of the transportation and other barriers to care that may be encountered by the client.
  • Ability to communicate medical information to health care professionals and care coordinators over the telephone.
  • Skill in organizing resources and establishing priorities.
  • Creative and analytical thinking; solid written and oral skills.
  • Strong problem solving, organizational, and time management skills.
  • Computer literate, Microsoft Office preferred.


Education and Work Experience:

  • High school diploma or GED; at a minimum of 2 years’ experience in serving the Medicaid population, preferably in the MD/DC area. Community Support Worker (CSW) or Certified Peer Support Worker (CPSW) certification preferred.
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Job Categories: Equal Opportunities. Job Types: Full-Time. Salaries: 60,000 - 80,000.

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