This position is part of an integrated interdisciplinary team serving women experiencing homelessness and housing instability through Ruth’s Place. The Aftercare Community Health Worker (ACHW) will provide trauma-informed, strengths-based, and person-centered support to women residing in shelter, transitioning into housing, and participating in aftercare services. The primary goal of this role is to improve overall quality of life by increasing access to healthcare, behavioral health supports, housing stability resources, and education on health-related social needs (HRSN or SDOH). This role combines direct case management, aftercare support, care coordination, and structured group facilitation into one full-time position.
The employee will provide individual and group-based interventions focused on healthy living, life skills, coping skills, recovery support, community engagement, and housing retention. The position will maintain a strong emphasis on group HRSN education through regularly scheduled evening programming at Ruth’s Place while continuing to support participants in home and community settings as appropriate. The employee will monitor the participant's ongoing needs and follow the “step down method,” gradually decreasing the frequency of meetings as the participant's HRSNs are addressed and the participant becomes stable. The employee should aim to have the participant’s HRSNs addressed by 12-18 months after the participant is discharged from Ruth’s Place.
The employee will work collaboratively with managed care organizations (MCOs), healthcare providers, behavioral health providers, social service agencies, landlords, other VOAPA programs, and community partners to facilitate groups, improve participant outcomes, and reduce recidivism into homelessness. Duties include but are not limited to: assessing participant needs, providing care coordination and options-based counseling, facilitating educational and supportive groups, maintaining documentation and statistics, supporting housing stability, coordinating referrals, developing community partnerships, and communicating participant progress with the interdisciplinary team.
1. Demonstrate professionalism and positive communication while interacting with participants, staff, partner agencies, volunteers, and the community.
2. Develop trusting, strength-based relationships with participants utilizing motivational interviewing and trauma-informed approaches.
3. Work evening shifts at the shelter and perform in-home or community-based work as assigned or required to meet participant needs.
4. Meet regularly with participants in shelter, transitional housing, permanent housing, or community settings to assess needs, evaluate progress toward goals, and provide interventions and referrals.
5. Provide aftercare and post-residential support services to assist former residents in maintaining stable housing, healthcare access, and community support to reduce recidivism.
6. Coordinate physical and behavioral healthcare services and assist participants with accessing medical providers, behavioral health services, insurance resources, transportation, and community supports.
7. Transport participants or self to appointments and meetings using either employee’s personal vehicle or an agency vehicle, depending on availability.
8. Assist participants with completing applications, scheduling appointments, navigating systems of care, and overcoming barriers to services.
9. Develop and maintain person-centered service plans and monitor progress toward identified goals.
10. Research, develop, coordinate, and facilitate group sessions (individually and in partnership with other agencies or educators) focused on, but not limited to:
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HRSN or SDOH needs oHealthy living and wellness
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Coping skills and emotional regulation oLife skills and budgeting
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Housing retention oRecovery and relapse prevention
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Communication and relationship skills oEmployment readiness
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Leisure and recreational activities
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Community engagement and self-sufficiency
11. Maintain and coordinate the shelter activity and group calendar, ensuring regular evening programming and educational opportunities are consistently available.
12. Facilitate supportive dialogue during group activities while encouraging engagement, participation, and peer support.
13. Monitor and manage group dynamics to maintain a safe, respectful, and therapeutic environment.
14. Assist residents in understanding and complying with shelter policies, program expectations, and community living guidelines.
15. Maintain accurate, timely, and compliant documentation within the program’s electronic health record system and on-site documentation locations, including:
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Case notes oGroup attendance
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Visit reports oAssessments
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Service plans oStatistical reports
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Referral documentation
16. Develop and maintain collaborative relationships with healthcare providers, community agencies, landlords, educational presenters, and referral partners to expand participant resources and opportunities.
17. Attend staff meetings, case conferences, trainings, and community-based meetings as assigned.
18. Communicate relevant participant progress, concerns, and updates to appropriate team members in a timely and professional manner.
19. Act as a liaison for Ruth’s Place and VOAPA by maintaining a positive and professional image in the community.
20. Assist with administrative duties, including answering doors or phones, filing, copying, data collection, reporting, scheduling, and maintaining program materials.
21. Respond appropriately to crises and consult with supervisory staff when policy clarification or emergency intervention is needed.
22. Clock in and out daily and ensure accurate submission of working hours.
23. Perform other duties as assigned.
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Integrity, discretion, and respect for confidentiality and privacy
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Critical thinking skills and an ability to work autonomously
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Excellent oral communication skills and the ability to deescalate misunderstandings, errors, or conflicts in a diplomatic manner
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Typing, computing, and data entry skills
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Strong empathy and interpersonal skills
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Good communication, interpersonal, and customer service skills
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Analytical skills
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Ability to prioritize and work under pressure
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Ability to provide traumainformed care
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Time management
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Organizational skills
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Attention to detail
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Strong spelling, math, and financial skills
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Documentation skills
To perform this job successfully, an individual must be able to satisfy each essential duty. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable employees with disabilities to perform the essential functions.
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Regularly required to stand, walk, sit, use hands to handle or feel, reach with hands and arms, climb stairs, talk, hear, and smell.
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Must be able to withstand being outside in all weather conditions
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Regularly lift and move up to 25 lbs.
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Ability to identify and/or distinguish between people, places and things.
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Ability to observe an area that can be seen up and down or to the left and right while remaining fixed on a given point.
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Must have a Pennsylvania driver’s license.
The employee in this position is preferred to possess an associate or bachelor's Degree in a human service or healthcare field or a combination of 2 years of experience in a similar social service and/or healthcare setting and a CHW certification or the willingness to obtain one. If an individual with relevant experience does not have an existing CHW certification, the organization is willing to assist with the process. FBI fingerprints, Pennsylvania State Police, PA Drivers History Record and Child Abuse clearances are required annually. A valid Pennsylvania driver’s license, valid insurance on a personal vehicle, and a positive driving history are required. The employee must possess a strong ability to make immediate decisions when faced with crisis or unusual situations. The employee must have a working knowledge of computer software, specifically the agency’s online system navigation sites such as Relias, PUPS, and Microsoft Office systems including Outlook, Excel, and Word, as well as effective written and verbal communication skills. EEO of "Participants with Disabilities" and "Veteran Status"/AA
The individual will report to work at Ruth's Place Women's Shelter. Ruth's Place is a 24/7 emergency shelter for women. The facility features an open-plan layout in which the residential bed area, living spaces, and kitchen are visible upon entry. Staff use a camera security system to monitor the premises and permit entry. This role routinely uses standard office equipment such as computers, phones, photocopiers, and filing cabinets. The role relies heavily on the use of internet and technology for documentation and referrals. The noise level in the work environment is usually moderate but can vary. The individual in this role should be prepared for conflicts or critical incidents to occur (infrequently). While the majority of time in this role will be spent within the shelter environment, the role also provides limited aftercare support in in-home settings of recently rehoused residents. As such, the role requires frequent transportation.
Volunteers of America of Pennsylvania’s (VOAPA) ministry of service is to empower vulnerable communities, families, and individuals through support and resources that lead to health and stability. We use evidence-based, data-driven information to develop community-based, contextualized, holistic, and empowering interventions. Our core values are: Person-Centered; Empowering; Community-Based; Responsive. VOAPA has regional offices located in Northeast, Lehigh Valley, Central, and Southwest Pennsylvania Communities.
