Location Work from Home Job Category Patient Support, Nursing and Nursing Support, Geisinger Health Plan Schedule Days Work Type Full time Department GHP Behavioral Health Team Date posted 06/11/2026 Job ID R-97765

Job Summary

The Certified Community Health Worker (CCHW) within the Social Needs Resource Hub (SNRH) provides patient-centered outreach, primarily through telephonic engagement, to individuals with identified social needs. Working within a team-based model, the CCHW collaborates with healthcare teams, community-based organizations (CBOs), and hub colleagues to assess needs and coordinate appropriate support. The CCHW utilizes motivational interviewing and problem-solving techniques to educate patients and connect them to community resources that address social determinants of health, including transportation, food insecurity, housing, financial strain, and utilities. This role includes facilitating referrals and partnering with CBOs through the Neighborly platform to ensure timely and effective linkage to services. The CCHW conducts follow-up outreach to confirm successful connections and address barriers, supporting a shared team workflow and accountability model. Accurate and timely documentation within Geisinger’s electronic medical record (EMR) is required to capture outreach efforts, referrals, and outcomes, supporting reporting, quality improvement, and program evaluation.

Job Duties

• Orientsandassesses newCommunityHealthWorkers.
• Providesregular assessmentofthelevelofproficiencydemonstratedbystaffduring theorientationperiodinordertosupport decisions to move staff along in training or refocus until proficiency is met.
• Assistsintheidentificationandoutreachofmedicallycomplex patients.
• Collaborateswiththemultidisciplinaryteaminthedevelopmentandimplementationofthecareplan.
• Engagespatients bywayofphonecall, homevisit,hospital visit,andaccompanyingpatientstoProvidersappointmentsasneeded.
• Completesvitalsigns.
• Identifiesgapsincareandconnectsmembers withresources.
• Facilitatestelemedicinevisits withmembersandproviders.
• Performsdiseasespecificeducation.
• ConductsMedicationReviewtoensuremedicationadherence.
• Conductssafetyevaluationsinpatientshome.
• Facilitatesadherencetotreatmentplanbyearlyidentificationandresolutionofgapsincare.
• Communicatesallconcerns toclinicalteamandmanager asnecessary,seeking supportandguidance proactively.
• Participatesinmultidisciplinaryteamconferenceinordertomaximizethetreatmentplan.
• ProvidesreinforcementofthetreatmentplanunderthedirectionoftheCaseManagerandLicensedSocial Workerand is available for consultation and case review as needed.

Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.

Education

High School Diploma or Equivalent (GED)- (Required)

Experience

Minimum of 1 year-Related work experience (Required)

Certification(s) and License(s)

Certified Community Health Worker (CCHW) - Pennsylvania Certification Board

Skills

Multitasking; Problem Solving; Clerical I; Communication

About Geisinger

Founded more than 100 years ago by Abigail Geisinger, the system now includes ten hospital campuses, a 550,000-member health plan, two research centers and the Geisinger Commonwealth School of Medicine. With nearly 24,000 employees and more than 1,700 employed physicians, Geisinger boosts its hometown economies in Pennsylvania by billions of dollars annually. Learn more at geisinger.org( opens in new window) or connect with us on Facebook( opens in new window), Instagram( opens in new window), LinkedIn( opens in new window) and Twitter( opens in new window).

Equal Opportunity Employer

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws.

Our Vision & Values

Everything we do is about making better health easier for our patients, our members, our students, our Geisinger family and our communities.

KINDNESS: We strive to treat everyone as we would hope to be treated ourselves.

EXCELLENCE: We treasure colleagues who humbly strive for excellence.

LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow.

INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation.

SAFETY: We provide a safe environment for our patients and members and the Geisinger family.

Our Benefits

We offer healthcare benefits for full time and part time positions from day one, including vision, dental and prescription coverage.