Job Summary

The Certified Community Health Worker (CCHW) within the Social Needs Resource Hub (SNRH) provides patient-centered outreach, primarily through telephonic engagement, to individuals with identified social needs. Working within a team-based model, the CCHW collaborates with healthcare teams, community-based organizations (CBOs), and hub colleagues to assess needs and coordinate appropriate support. The CCHW utilizes motivational interviewing and problem-solving techniques to educate patients and connect them to community resources that address social determinants of health, including transportation, food insecurity, housing, financial strain, and utilities. This role includes facilitating referrals and partnering with CBOs through the Neighborly platform to ensure timely and effective linkage to services. The CCHW conducts follow-up outreach to confirm successful connections and address barriers, supporting a shared team workflow and accountability model. Accurate an...