Remote Community Health Worker

Who We AreEvergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach to kidney care. We believe patients living with kidney disease deserve the best care. We are committed to improving patient outcomes and improving quality of life by delaying disease progression, shifting care to the home, and accelerating kidney transplants.We help nephrologists focus on the right patients at the right time across the full care spectrum. We do this by providing them with the best-in-class interdisciplinary clinical resources, analytical insight and tools, and services to patients. We listen to the needs of our patients, our employees, and our client partners, continually working to push beyond the status quo in which the care system manages patients today.Who You AreYou are devoted, compassionate, and enjoy being on the front lines of healthcare, changing the lives of patients by supporting them and the team by focusing on customers. You’re excited about being part of a team that is building a healthcare delivery model that ensures the highest possible quality of life and best outcomes for those in our care. You believe people living with kidney disease deserve the best person-centered, holistic, comprehensive care and want to influence the healthcare system to drive towards that. You thrive in innovative and evolving environments with high rates of change.Your RoleThe Community Health Worker (CHW) at Evergreen Nephrology supports high-quality, patient-centered care by providing exceptional patient service, care coordination, and connection to community-based resources. This role serves as a trusted liaison between diverse, underserved, and vulnerable populations and the health and social service systems that support them, with a strong focus on building trust, engagement, and patient empowerment.Working within an interdisciplinary care team including Nurse Practitioners, Nurse Care Managers, Care Coordinators, Dietitians, Pharmacists, Licensed Clinical Social Workers, Population Health Social Workers, and Psychiatrists the CHW leverages Evergreen’s integrated technology platform to help patients access services aligned with their individual needs. The CHW also partners with clinical teams and leadership to support community outreach initiatives designed to promote, maintain, and improve the health and well-being of patients and their families.You will take the lead on comprehensive care coordination with a focus on identifying and addressing Social Determinants of Health while partnering with the interdisciplinary care team. You will be an essential resource for patients, assisting them in navigating the healthcare system, accessing resources and support, and achieving better health outcomes.Role ResponsibilitiesSome responsibilities may vary based on specific patient programs; however, the primary duties of the Community Health Worker include:Patient Engagement & OutreachConduct telephonic and virtual outreach to patients identified with high social determinants of health (SDOH) needs.Establish trust and serve as a primary point of contact for patients enrolled in the CHW program.Build culturally competent relationships that promote engagement, encouragement, and patient empowerment.Care Coordination & NavigationServe as a liaison between patients, families, clinical teams, dialysis centers, and community-based service providers.Facilitate seamless transitions of care across care settings to support comprehensive, patient-centered care.Assist patients with enrollment in health and social services, including completing applications, paperwork, and required documentation.Support clinical staff by coordinating care activities, identifying resources, and addressing barriers to care.Social Determinants of Health Conduct comprehensive assessments to identify social, economic, cultural, and environmental factors impacting patient health.Recommend gap closures and contribute SDOH findings to individualized care plans to improve quality and health outcomes.Connect patients to appropriate resources, including housing assistance, transportation, food security, utilities, and community support programs.Resource Management & Follow-UpGuide patients in understanding and accessing available health and social services within Evergreen Nephrology and external organizations.Follow up on and track referrals and outcomes related to pharmacy services, durable medical equipment (DME), home care, and other supportive services.Assist with identifying, scheduling, and coordinating transportation for medical and community appointments.Build and maintain up-to-date resource inventories across service areas and multiple states.Member Advocacy & SupportAdvocate for patients by identifying barriers to care, addressing inequities, and ensuring appropriate interventions and support are provided.Support patients and families in navigating complex systems and ove