Community Health Worker

Role Summary: The Community Health Worker (CHW) provides hands-on support to MI Choice participants with care transitions, community resource coordination, health education, and follow-up after hospital or nursing facility discharge. The CHW helps participants access services, understand care instructions, manage appointments and medication-related needs, and remain safe and independent in the community. This role works closely with the Supports Coordinator and maintains timely, accurate documentation of all participant contacts and interventions. 

Responsibilities and Duties 

• Assist participants who are re-enrolling in MI Choice, transitioning from a hospital or nursing facility, or otherwise needing additional hands-on support to safely remain in the community.  

• Help participants access community resources and services, including housing, employment, benefits, transportation, and other supports that promote health, safety, and independence.  

• Monitor Bamboo Health discharge notifications for nursing home or hospital transitions and complete required follow-up with participants to help ensure a safe, timely, and smooth return to the community 

• Conduct required transition follow-up activities, including visiting participants at home within three (3) days of hospital or facility discharge to review discharge instructions, medications received, prescriptions that need to be filled, and the importance of physician follow-up.  

• Complete follow-up contact within thirty (30) days of discharge to assess whether the participant obtained medications, followed up with the physician, and carried out discharge recommendations.  

• Assist participants with scheduling appointments, obtaining medication refills, accessing skilled care or physician-ordered services, and coordinating the supplies and supports needed to safely remain in or return to their home. 

• Provide practical health education, and skills training to support independence, including medication follow-up, understanding medical information, chronic condition self-management, communication, problem solving, and recognizing when to seek additional care.  

• Support participants with falls prevention and home safety by observing environmental risks, reinforcing safety recommendations, and communicating concerns to the Supports Coordinator for further follow-up.  

• Help reduce avoidable hospitalizations and emergency department utilization by reinforcing discharge plans, encouraging follow-up care, supporting medication adherence, and helping participants address barriers to care.  

• Visit participants in hospitals or nursing facilities, as needed, to support discharge planning, help facility staff identify the appropriate Supports Coordinator contact, and assist with coordination when a participant is returning home or transitioning through temporary rehabilitation.  

• Maintain close collaboration with the participant’s Supports Coordinator, promptly reporting participant concerns, unmet needs, medication discrepancies, changes in condition, and other issues affecting the participant’s care or independence.  

• Responds to referrals submitted by the Supports Coordinator and completes appropriate follow-up based on identified participant needs. 

• Complete timely, accurate, and thorough progress notes documenting participant contacts, education provided, follow-up activities, needs identified, actions taken, and outcomes, so the Supports Coordinator remains informed of all interventions and findings. 

• Hand-deliver participant waiver folders annually to CQAR home-visit participants. 

• Other duties as assigned.  

Required Knowledge, Skills and Abilities 

• Experience working with older adults, individuals with disabilities, or vulnerable populations preferred.  

• Experience supporting participants during transitions of care.  

• Preferred experience with Medicaid, waiver services, or long-term services and supports.  

• Experience with fall prevention education, health education, or resource coordination.  

• Ability to maintain confidentiality and handle sensitive participant information appropriately.  

• Basic computer skills and ability to learn required documentation systems.  

• This position requires regular local travel to participant homes, hospitals, nursing facilities, and community locations to provide in-person support and care coordination.  

• Valid driver’s license, reliable transportation, and proof of insurance is required. 

Education and Experience 

• High school diploma or equivalent required.  

• Community Health Worker training or certification preferred.