Community Health Worker Coordinator

Millennium Collaborative Care, PPS - Buffalo, NY (30+ days ago)


Community Health Worker will primarily work with targeted populations. CHW will work closely with medical providers, primary care teams, and other organizations agencies to improve patient care and outcomes. The CHW will engage, enroll and support patients with unmanaged chronic diseases. They will act as a liaison to link and connect patients to community service organizations that address the Social Determinants of Health and assist in patient education.


  • Of and from the community being targeted and/or significant experience with and knowledge of the community, including shared life experiences.
  • A minimum of six (6) months work experience in public health or in another position with the provision of social service, supportive services, personal care, or related duties.
  • Basic office/customer service experience preferred
  • Valid NYS driver’s license and reliable transportation
  • CHW Certification, preferred
  • Knowledge of NYS DSRIP and Millennium Collaborative Care

Knowledge, Skill and Key Responsibilities:

  • Facilitate/support communication and coordination of services between referring providers and community-based organizations
  • Effectively work with people (staff, clients, doctors, agencies, etc) from diverse backgrounds in reducing cultural and socio-economic barriers between clients and institutions
  • Compassionate, caring, and dedicated to understanding the needs and strengths of patients, their family, and the community.
  • Possess basic working knowledge of community-level health issues and community systems and resources
  • Reliable and dependable, function independently, have flexibility and personal integrity
  • Able to communicate effectively with patients, their families, personnel, and other agencies
  • Able to quickly establish rapport with patients and convey a sense of competence
  • Able to relate to patients and life situations in a supportive, constructive, and professional manner
  • Able to work as part of a team and interact with all departments within the organization
  • Work as part of the multi-disciplinary care team (i.e., Pharmacist, Social Worker, Nurse, etc.) on development of a treatment plan targeting barriers to stability and active engagement in medical/behavioral health care.
  • Manage assigned caseload of clients under oversight of assigned clinical staff.
  • Conduct assessments with clients, utilizing an asset and strength based approach, identifying access and use of health/behavioral health services, housing safety, food security, financial resources, education, employment and social support networks.
  • Assist clients to set personal goals, provide referrals for services to community agencies as required, conduct eligibility determination, assist with completing applications and registration forms, and assist with appointment management. Act as a client advocate and liaison between the client/family and community service agencies.
  • Responsible for providing consistent communication to the assigned clinical staff, providers, and CHW Supervisor to report progress toward goals and any barriers to achieving progress. Participate in client case conferences providing providers with updates on clients’ progress/barriers to achieving progress.
  • Able to travel locally for meetings with patients, providers, or community based organizations
  • Able to problem solve and come up with creative solutions to help patients overcome barriers
  • Ability to partner with patients to engage in customized care and service programs, and to recognize clients with severe problems and link to other services and/or communicate that information to the medical or social work staff
  • Continuously expand knowledge and understanding of community resources, services and programs provided; human relations and the procedures used in dealing with the public as part of a service or program; volunteer resources and the practices associated with using volunteers, operations, functions, policies and procedures associated with the department or program area, procedures and resources available to handle new, unusual or different situation
  • Strong verbal communication skills, able to communicate clearly and politely
  • Basic computer and data entry skills, ability to document interactions with patients
  • Able to maintain confidentiality
  • Other duties as assigned


  • High School diploma or GED or Associate degree in related field.

Job Type: Full-time


  • High school (Required)

Work authorization:

  • United States (Preferred)