Community Health Worker (CHW)- On-Site/ Field-Based

About this role

** This role provides on-site and field support across partnered health centers in Richfield and Kanosh, UT. Candidates must reside within commuting distance of local clinic sites. **

About Activate Care:
At Activate Care, we’re on a mission to improve health equity and drive improved health outcomes across the country. Our Community Care Record platform enables healthcare and community organizations to coordinate care for populations challenged with health-related social needs. Path Assist is our tech-enabled community health worker program for HRSN utilizing an evidence-based, structured intervention. Our goal is simple: increase health confidence, improve self-efficacy, and reduce inappropriate healthcare spending.
Role Overview:
Activate Care is seeking a Community Health Worker (CHW) to support the Utah LIFT Path Assist for Chronic Disease program. The CHW will work closely with patients, participating FQHC clinics, and Activate Care's program team to help adults with chronic conditions overcome barriers to care, successfully access telehealth services, and use digital tools and approved educational resources to support chronic disease self-management.
Each CHW will be aligned with a participating clinic(s) and will provide a combination of in-person, telephone, video, secure messaging, and technology-enabled support. The CHW will serve as a trusted connection between patients, clinical teams, and community resources while helping patients develop and achieve individualized health goals.
The CHW is a non-clinical role and will not diagnose, prescribe, or provide medical advice. Clinical questions and concerns will be escalated to the appropriate licensed healthcare provider.
Responsibilities:

• Conduct outreach to patients referred by participating FQHC clinics and explain the Path Assist program.

• Engage eligible patients in the program and complete consent, required intake, assessments, and enrollment activities.

• Identify patient-specific goals and barriers and document support and follow-up provided.

• Maintain regular contact with participants based on their level of need and program requirements.

• Support patients with appointment preparation, follow-up, and completion of recommended services.

• Support patients in understanding and following next steps recommended by the patient's healthcare team.

• Track goals, tasks, referrals, and progress throughout the participant's enrollment.

• Support patients in using CareLink Navigate for secure communication, reminders, education, goal tracking, and resource navigation.

• Assess each patient's comfort with technology, internet connectivity, digital literacy, and readiness to use telehealth.

• Help patients understand when and how telehealth may be used as part of their care.

• Support telehealth scheduling, reminders, visit preparation, technology setup, and connectivity troubleshooting.

• Coach patients on use of smartphones, patient portals, video platforms, and other approved digital tools as needed.

• Help patients overcome technology-related barriers that may prevent them from completing telehealth visits.

• Follow up after telehealth encounters to support completion of provider-recommended next steps and identify any additional access barriers.

• Provide education and coaching related to chronic disease self-management, leveraging and distributing relevant WebMD Ignite chronic disease materials.

• Help patients access and understand approved educational materials and provider-recommended next steps.

• Use motivational interviewing, health coaching, and goal-setting techniques to support patient engagement and follow through.

• Identify barriers that may interfere with chronic disease management and work with patients to develop practical solutions.

• Refer to local disease self-management programs as relevant.

• Screen for social needs that may affect the patient's health or ability to follow their care plan, including transportation, food access, housing, affordability, language, health literacy, and other barriers.

• Refer patients with identified health-related social needs to Utah 211 for resource navigation and assistance.

• Help patients utilize the CareLink Navigate self-service resource directory.

• Help patients identify and address practical barriers to health and social care access.

• Document patient outreach, assessments, care plan-related goals, referrals, interventions, follow-up, and outcomes in CareLink accurately and in a timely manner.

• Collaborate closely with clinic staff to support referral, communication, and care coordination workflows.

• Communicate patient barriers, care-coordination needs, and relevant updates to authorized clinic staff.

• Follow established clinical escalation protocols when a patient reports symptoms, concerns, or needs outside the CHW scope of practice.

• Participate in clinic huddles, case reviews, or implementation meetings as appropriate.

• Build strong working relationships with providers, care teams, community partners, and other members of the LIFT program.

• Participate in CHW supervision, coaching, continuing education, and performance feedback.

• Support program goals related to enrollment, engagement, screening, referrals, goal-setting, telehealth access, and participant retention.

• Maintain strict compliance with HIPAA, privacy, security, documentation, and program policies.

• Other duties as assigned.
Requirements
Qualifications & Skills:

• High school diploma or equivalent required.

• Community Health Worker (CHW) certification or prior experience in CHW, patient navigation, care coordination, peer support, health education, or community outreach roles preferred.

• Experience working in an FQHC, rural healthcare setting, Medicaid program, or community-based organization preferred.

• Experience supporting patients with chronic conditions using motivational interviewing, health coaching, or chronic disease self-management…