Community Health Worker – Behavioral Health

Job Summary

The Community Health Worker is responsible for the coordination with primary care and behavioral health to deliver comprehensive services to patients and families throughout the continuum of care.


Associate degree in a human service-related field or equivalent work experience.  Bachelors preferred.  Mental illness or addiction experience helpful.  Bilingual/bicultural in Spanish preferred.

Representative Job Duties

Coordination and facilitation of patient care across the continuum of care:

  • Proactively contacts patients with due/overdue appointments, due/overdue tests, immunizations or screenings, or unmet
  • Outreach to high-risk patients
  • Identifies patients with barriers to referrals/transition and help patients address
  • Works collaboratively with the care team to improve and ensure quality/timely care for high-risk patients
  • Initiates and maintains trusting relationships with children and families
  • Conduct home visits and site visits of community partners

Patient advocate/ liaison:

  • Serves as point of contact for
  • Identifies and establishes relationships with community resources, links patients with community Works collaboratively with school systems, early intervention specialists and assists in developing and increasing community collaboration and advocacy.
  • Assists patients in problem solving potential issues related to referrals
  • Assists patient in utilizing transportation resources to attend medical
  • Works with the Enroller to help patients with obtaining health insurance

Patient support/transition of care:

  • Track and support identified high risk patients when they obtain services outside of practice like emergency room, or other health care
  • Assists with follow up of emergency room discharges by telephone call within 48 hours for identified high risk
  • Works with the Provider team to facilitate prompt (48 hours) follow-up for identified high risk hospitalized
  • Ensure accurate and timely documentation in Electronic Health

Promotion of patient health behaviors changes:

  • Follows up with patient to ensure appropriate intervals between office
  • Ensure that the patient and family understand the care plan and associated instructions as per
  • All outreach activities are recorded in the appropriate template at the time of contact in respective patients’

Quality improvement and performance measurement:

  • Generate reports as required
  • Outreaches to patients on registries and schedules appointments accordingly.
  • Assist in data collection and generation of patient registry reports.
  • Participate in Performance Improvement/ Continuous Quality Improvement activities as

Other Educational/Technical Assistance Duties

  • As requested, attend trainings in other subject areas and report and/or provide training to SBCHC staff (and others).
  • As requested, attend community and health fairs representing SBCHC’s interest
  • Provide technical assistance to other SBCHC committees and assist as appropriate in the development of programs and

Functions as member of the primary care team

  • Participates in development of patient care plans with care team
  • Meets with care team on a regular basis

Competitive benefits package. Generous tuition assistance after 1 year of service.

Apply Now

Please submit cover letter and resume to

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What You're Saying

“I feel that it is a well-oiled machine, with Dr. Brout at South Boston. I just can't say enough good things! They know why I am there without a computer, since everybody knows what is going on with me, all staff. Everybody is on the same page, for a level of healthcare I had never experienced.”
Family Medicine/Dr Brout
Family Medicine Patient 2022
“I like the doctors my son has. They listen, are very understanding, and seem like they care. I just like how they are with my son.”
BH Parent
Parent of Behavioral Health Patient 2022
“I like the attentiveness and feeling heard. I appreciate the fact that providers always make me feel involved in decisions.”
Behavioral Health
Behavioral Health Patient 2022
“I like that the service is more personalized because you know the people, and that is very important.”
Dental Patient 2022
“I liked that they were attentive and fast. They gave me the support I needed and were empathetic and organized. I went to a lot of departments, and all of the staff was this way.”
Family Medicine
Family Medicine Patient 2022
“The staff in the lab, Verinta or "V," is amazing. My son was literally giddy with delight at her joking and playfulness. He was actually so happy with her, he didn't react to the blood draw, but then cried outside a tiny bit with a delayed reaction like "hey, wait, that hurt." She is an absolutely phenomenal addition to the phlebotomy team! Overall, a great experience.”
May 2019
Parent of a Pediatric Patient
“Dr. Kane always asks me if I understand everything and whether or not I need further clarification... I really appreciate him explaining everything so in depth.”
Eye Care Patient 2018
“There’s an emphasis on education here. Dr. Chiakpo and Marianna (a nurse in training) provided a lot of background concerning my issue and even brought in diagrams, which I greatly appreciated, since I’m a visual learner. They both gave me space to ask questions on everything. I really appreciated the time they spent with me.”
Family Medicine Patient 2018
“I truly enjoyed the sweetness of Dr. Biffi. She was very detailed in her explanations, and thoroughly checked and re-checked everything. She really impressed me.The assistant was also very good, dedicated, and professional.”
Eye Care Patient 2018
“My ride was late, but Dr. Green waited an hour for me. When I got there, she took me right in, so that was very nice. She gave me a prescription; she actually brought the prescription all the way outside to give it to me, since I had forgotten it. She is excellent! Everyone is very nice and very understanding. I really liked the center; everyone was very cordial to me.””
Adult Medicine Patient 2018