Job Description

Reports To: PSH Nurse Manager

Location: Permanent Supportive Housing Sites

Overview

The Community Health Worker (CHW) helps increase access to health services for individuals who have experienced homelessness through transportation coordination, outreach, medical care coordination, and peer support. This position provides a variety of specialized services to individuals with complex medical, behavioral health, and social needs. The CHW is expected to demonstrate an understanding of mental illness, homelessness, and addiction and be willing and ready to engage with clients who struggle with these issues at all levels. The CHW is responsible for facilitating linkages to health care services, assisting with eligibility and benefits renewals, and supporting individuals in the self-management of their conditions. Travel by car and/or public transportation is required across multiple service sites in Houston.

Duties and Responsibilities
Care Coordination

• Assist clients in gaining access to and navigating a primary health care medical home and other community-based services (e.g., behavioral health, housing, legal aid).
• Support clients in preparing for upcoming medical and behavioral health appointments.
• Coordinate transportation and accompany clients to medical or social services appointments, as needed.
• Maintain an updated calendar of assigned clients’ medical and care-related appointments.
• Assist clients with accessing benefits, such as durable medical equipment and home health providers.
• Provide basic client advocacy, planning, and coordination support.
• Conduct consistent follow-up with clients regarding appointments, care plans, and health goals.
• Conduct relationship-building visits with clients and promote harm reduction strategies.
• Assist clients with applying for or renewing benefits, including Medicaid, SSI/SSDI, Healthy Texas Women, SNAP, and other available programs.
• Provide culturally and linguistically appropriate health education and resource navigation.
• Conduct outreach and prevention education for individuals with chronic disease or in need of a medical home.

Multidisciplinary Team Collaboration

• Collaborate closely with HHH’s on-site medical team, the housing partner’s staff, and SEARCH Homeless Services’ clinical case managers to ensure coordinated, person-centered support for each resident
• Participate actively in regular supervisory and team meetings, training sessions, and planning activities.
• Complete all necessary documentation, forms, and case notes in a timely and accurate manner.
• Build relationships with area service providers to enhance referral pathways and awareness of available community resources.
• Coordinate and continuously refine referral processes between the community health center and supportive housing sites.
• Works at sites and community locations as assigned by supervisor, including clinic-based, mobile, or partner agency settings.

Support HHH Mission

• Demonstrates a commitment to HHH’s mission of promoting health, hope, and dignity for individuals experiencing homelessness through equitable and compassionate care.
• Upholds trauma-informed, culturally responsive, and patient-centered principles in all interactions, contributing to an inclusive and supportive environment for patients and team members.
• Actively contributes to a culture of collaboration, accountability, and innovation in service of our goal to eliminate health disparities and advance systems-level change.

Minimum Qualifications 

• High school diploma or GED
• Strong interpersonal and social skills with demonstrated ability to collaborate with a variety of individuals from a wide range of professional and personal backgrounds.
• Communicates and works well within a collaborative team environment.
• Reliable transportation and willingness to travel within the community, including between clinic sites or outreach locations.

Preferred Qualifications

• Strong organizational skills.
• Able to operate small office equipment, including photocopier, telephone, and personal computer.
• Basic knowledge of Microsoft Office.
• Bilingual English and Spanish preferred
• HHH values lived experience as an essential form of expertise. Individuals who have experienced homelessness, housing instability, or other barriers to healthcare access are strongly encouraged to apply.

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