Community Health Worker

Position Summary

The MSM Community Health Worker ( CHW ) helps adults with epilepsy who often go to the emergency room. The CHW provides support through care coordination, education, and help finding services. The CHW works closely with Grady care teams, Transitions of Care ( TOC ) staff, and community partners. The goal is to help patients get the care they need, build epilepsy self-management skills, provide access to community resources, and connect to primary care after emergency or specialty care.

Minimum Qualifications

High school diploma or equivalent required. Completion of a Community Health Worker training or willingness to complete one. Experience working with people with chronic conditions, epilepsy, or frequent emergency room use is strongly preferred. Ability to work with people from different backgrounds and understand social needs that affect health. Strong communication and relationship-building skills. Ability to work as part of a healthcare team. Basic computer skills and ability to document in electronic health records (such as EPIC ). Reliable transportation and ability to travel for home visits and community appointments.

Preferred Qualifications

Associate or Bachelor’s degree in public health, social work, health education, or a related field is preferred. Experience working in emergency departments, neurology, or transitions-of-care programs. Knowledge of local healthcare systems and financial assistance resources. Experience with patient education, care navigation, or community outreach. Bilingual or multilingual skills that reflect the communities served.

Description of Job Duty

Key Roles and Responsibilities Clinical Coordination & Transitions of Care

• Work with the research team to help identify and refer patients based on study guidelines.
• Work closely with the TOC Care Coordinator to support smooth care transitions.
• Share patient updates during weekly TOC case meetings when needed.
• Help decide when in-person follow-up with the TOC team is needed. Care Coordination & Patient Engagement
• Plan and complete home visits with patients during the program.
• Call patients regularly to check in, offer support, and encourage care participation.
• Go with patients to neurology, specialty, or primary care appointments when needed.
• Meet patients on the day of their appointments and help guide them through the visit process. Goal Setting & Self-Management Support
• Help patients set small, realistic goals that matter to them.
• Offer encouragement and continued support during the program.
• Use teach-back methods to make sure patients understand appointment and transportation steps.
• Help patients learn to manage their care on their own before leaving the program. Access to Care & Resource Navigation
• Help patients apply for Grady Financial Assistance programs.
• Support patients in getting prescribed medications after clinic visits.
• Help solve barriers to care such as transportation, medication access, or missed appointments. Monitoring, Assessment & Documentation
• Complete monthly and bi-monthly phone and home visit assessments following the program plan.
• Work with the TOC Care Coordinator to complete SF-20 assessments and document them in EPIC .
• Track patient progress as they move from neurology and specialty care to primary care. Program Completion & Graduation
• Introduce patients to their Primary Care Provider ( PCP ) team at program completion.
• Teach patients how to schedule follow-up appointments on their own.
• Support the move from specialty and TOC care to ongoing primary care.