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Key Responsibilities and Required Skills for Community Health Worker

💰 $35,000 - $55,000

Public HealthCommunity OutreachHealthcare

🎯 Role Definition

A Community Health Worker (CHW) is a frontline public health professional who builds trusting relationships within communities to promote health equity, prevent disease, and increase access to clinical care and social services. CHWs conduct outreach, provide culturally competent health education, perform home visits and care coordination, identify social determinants of health, complete referrals to community resources, document encounters in electronic health records (EHR/EMR), and support population health initiatives. This role requires strong communication skills, community knowledge, and the ability to work across clinical and social service systems to improve outcomes for individuals and groups.

📈 Career Progression

Typical Career Path

Entry Point From:

  • Peer Support Specialist or Community Outreach Volunteer transitioning into door-to-door outreach and client advocacy.
  • Medical Assistant or Clinic Support Staff who take on patient education and care navigation responsibilities.
  • Case Aide, Social Services Assistant, or Behavioral Health Technician with community-facing experience.

Advancement To:

  • Care Coordinator or Patient Navigator with responsibility for complex cases and interdisciplinary care plans.
  • Community Programs Supervisor or CHW Team Lead managing outreach programs and supervising CHW staff.
  • Public Health Educator, Population Health Analyst, or Program Manager designing interventions and evaluating outcomes.
  • Licensed Social Worker or Care Manager (with further education/certification) handling clinical case management and counseling.

Lateral Moves:

  • Patient Navigator focusing on specialty-specific navigation (e.g., cancer, diabetes, maternal health).
  • Case Manager within social services or community-based organizations.
  • Outreach Specialist in schools, housing authorities, or non-profit agencies.

Core Responsibilities

Primary Functions

  • Conduct proactive community outreach and engagement by identifying and establishing rapport with at-risk individuals and priority populations through door-to-door canvassing, phone outreach, community events, and clinic-based contact to increase access to health services and preventive care.
  • Perform comprehensive intake assessments that screen for medical, behavioral health, social, and environmental needs (housing, food security, utilities, transportation) and document findings in the electronic health record (EHR) following program protocols and HIPAA requirements.
  • Develop individualized, culturally appropriate care plans and goal-setting with clients, using person-centered approaches and motivational interviewing to promote behavior change, treatment adherence, and self-management for chronic conditions such as diabetes, hypertension, and asthma.
  • Provide health education and counseling on disease prevention, medication adherence, prenatal/postpartum care, immunizations, sexual health, mental health awareness, and substance use harm reduction using evidence-based materials and plain-language communication.
  • Facilitate warm handoffs and referrals to primary care providers, specialty clinics, behavioral health services, social service agencies, housing programs, food banks, and legal resources; track referral outcomes and follow up with clients to close referral loops.
  • Conduct home visits and community-based assessments to evaluate living conditions, safety risks, medication management, and social support networks; deliver basic health screenings (blood pressure, glucose checks) and report clinical findings to supervising clinicians.
  • Serve as a trusted patient navigator by scheduling appointments, arranging transportation, accompanying clients to medical or social service visits when appropriate, and assisting with paperwork and insurance enrollment to reduce barriers to care.
  • Coordinate multi-disciplinary care by participating in case conferences, communicating client needs to clinicians and social service partners, and advocating for clients within health system and community networks to ensure continuity of care.
  • Collect, maintain, and submit accurate program data, encounter notes, outreach logs, and outcomes metrics into databases or institutional EHRs for reporting, quality improvement, and grant compliance, ensuring timeliness and data integrity.
  • Empower clients and family members with self-management techniques, teach return-to-work or activity plans, and connect individuals to community support groups to strengthen social support and long-term health outcomes.
  • Monitor client progress through regular follow-up calls and visits, document changes in health status or social needs, update care plans accordingly, and escalate urgent clinical or safety concerns to supervising nurses, social workers, or physicians.
  • Implement culturally and linguistically appropriate health promotion campaigns and community workshops in collaboration with public health initiatives, local schools, faith-based organizations, and community centers to reach diverse audiences.
  • Support disease surveillance and public health initiatives by identifying emerging health trends in the community, participating in vaccination drives, outbreak education efforts, and contact tracing when trained and authorized.
  • Provide crisis support and de-escalation for clients experiencing behavioral health crises, domestic violence, or acute social needs by following safety protocols, arranging immediate referrals, and coordinating with emergency services when necessary.
  • Participate in continuous quality improvement activities by providing feedback on program protocols, suggesting workflow improvements, identifying gaps in service delivery, and helping implement pilot projects that address systemic barriers.
  • Maintain up-to-date knowledge of community resources, eligibility criteria, and referral processes to ensure effective linkage to housing, SSI/benefits enrollment, employment services, and legal advocacy.
  • Support enrollment and renewal processes for insurance, Medicaid/CHIP, SNAP, WIC, and other benefits by assisting with applications, document gathering, and follow-up communications to improve coverage rates and access to care.
  • Lead or co-facilitate group education sessions, support groups, and chronic disease self-management workshops using adult learning principles and interactive teaching methods tailored to community literacy levels.
  • Uphold confidentiality, ethical standards, and patient rights in all interactions, manage sensitive information per HIPAA and organizational policies, and document consent forms and releases as required.
  • Build and maintain partnerships with local stakeholders, community-based organizations, faith leaders, schools, and municipal agencies to strengthen referral networks, resource sharing, and coordinated community responses.
  • Participate in professional development and certification programs (e.g., CHW certification, CPR/First Aid, motivational interviewing) to expand clinical knowledge, cultural competence, and technical skills to better serve clients.
  • Track outcomes and contribute to program evaluation by collecting qualitative success stories and quantitative metrics (e.g., reduced emergency department visits, improved chronic disease indicators, completed referrals) to demonstrate impact for funders and stakeholders.

Secondary Functions

  • Assist with program outreach planning, event logistics, and the creation or translation of educational materials and social media content to increase community awareness and engagement.
  • Support data collection efforts for grants and evaluation by conducting structured interviews, administering standardized surveys, and ensuring timely submission of required documentation.
  • Participate in staff meetings, interdisciplinary huddles, and case review sessions to coordinate services, share best practices, and align on care strategies for complex clients.
  • Cross-cover other community-facing roles during staffing shortages, including reception, appointment reminders, and resource navigation to maintain continuity of services.
  • Contribute to clinic flow optimization by identifying bottlenecks in patient access, suggesting operational improvements, and piloting workflow changes that improve client experience.
  • Provide mentorship and on-the-job training to new CHWs, interns, or volunteers on community engagement techniques, documentation standards, and client safety protocols.
  • Represent the organization at community coalitions, advisory boards, and health fairs to gather community input, identify emerging needs, and advocate for culturally responsive services.
  • Assist in basic supply inventory management for outreach materials, screening equipment, and PPE; request replenishment and ensure outreach teams are equipped for safe fieldwork.
  • Help develop client-facing resource guides, referral directories, and maps of services to streamline navigation and reduce duplication of effort across partners.
  • Document and report safety incidents, client grievances, and near-misses to supervisors promptly and participate in remedial actions and follow-up as needed.

Required Skills & Competencies

Hard Skills (Technical)

  • Case management and care coordination experience, including intake assessments, care planning, and monitoring outcomes across clinical and social service systems.
  • Proficiency with Electronic Health Records (EHR) / Electronic Medical Record (EMR) systems for documentation, referrals, and reporting (e.g., Epic, eClinicalWorks, Allscripts, or similar).
  • Strong knowledge of community resources, public assistance programs, eligibility criteria, and referral pathways (Medicaid, SNAP, WIC, housing services, transportation).
  • Health education and chronic disease self-management skills, including structured curricula delivery and ability to teach medication adherence, glucose monitoring, and blood pressure control.
  • Motivational interviewing and brief behavioral counseling techniques to support behavior change and enhance treatment adherence.
  • Bilingual language skills (e.g., Spanish/English, Portuguese/English, Mandarin/English, Arabic/English) preferred for serving diverse populations and improving health equity.
  • Basic clinical screening competencies such as measuring blood pressure, blood glucose testing, BMI, and documenting vitals safely and accurately.
  • HIPAA, confidentiality, and ethical compliance knowledge with experience handling protected health information and consent documentation.
  • Practical knowledge of community-based harm reduction practices and overdose prevention (e.g., naloxone distribution protocols) where applicable.
  • Basic digital literacy and ability to use mobile outreach tools, data entry platforms, telehealth interfaces, scheduling software, and Microsoft Office/G Suite.
  • Familiarity with quality improvement methodologies, data collection for performance metrics, and ability to contribute to program evaluation and reporting.

Soft Skills

  • Exceptional verbal and written communication skills tailored to diverse literacy levels and cultural backgrounds.
  • Empathy, cultural humility, and the ability to establish trust with clients experiencing trauma, stigma, or complex social needs.
  • Strong organizational and time-management skills to prioritize caseloads, follow up on referrals, and meet documentation deadlines.
  • Problem-solving and resourcefulness in navigating fragmented systems and finding practical solutions for clients.
  • Advocacy and negotiation skills to effectively liaise with healthcare providers, social service agencies, landlords, and insurers on behalf of clients.
  • Resilience and adaptability to work in dynamic field settings, including home visits, shelters, clinics, and community events.
  • Collaborative team player able to coordinate with clinicians, social workers, and community partners in an interdisciplinary environment.
  • Professional boundary setting and self-care awareness to prevent burnout while maintaining supportive client relationships.
  • Attention to detail and accuracy in data collection, reporting, and maintaining client records for regulatory compliance.
  • Conflict resolution and de-escalation skills to handle tense situations safely and maintain client and staff safety.

Education & Experience

Educational Background

Minimum Education:

  • High school diploma or GED required; demonstrated community experience and training may substitute for formal education for many CHW positions.

Preferred Education:

  • Associate degree or certificate in Community Health, Public Health, Social Work, Behavioral Health, Nursing, or related health field.
  • Completion of an accredited Community Health Worker training program or CHW certification where available.

Relevant Fields of Study:

  • Public Health
  • Community Health
  • Social Work
  • Nursing
  • Health Education
  • Behavioral Health

Experience Requirements

Typical Experience Range:

  • 0–3 years (entry-level to early-career CHWs are commonly hired), though many roles seek at least 1 year of community outreach, case management, or health education experience.

Preferred:

  • 1–3+ years of direct community outreach, patient navigation, or case management experience in a public health, clinic, or social service setting.
  • Experience working with underserved, multilingual, and multicultural populations; familiarity with local community organizations and social service systems.
  • Prior experience with EHR documentation, referral tracking, and performance reporting preferred.
  • Certifications such as CPR/First Aid, CHW certification, or training in motivational interviewing and trauma-informed care are highly desirable.
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