Community Resource Navigator: Community Health Worker – Housing & Homelessness

Job Description Summary

The Community Resource Navigator: Community Health Worker – Housing & Homelessness is a grant-funded position that reports to the Program Director of Community Navigation within MUSC's Population Health Department. This position is dedicated to providing outreach, navigation, advocacy, and care coordination for individuals experiencing housing insecurity or homelessness throughout the Tri-County region (Charleston, Berkeley, and Dorchester Counties).
The Community Health Worker (CHW) works collaboratively with patients, healthcare providers, interdisciplinary care teams, housing organizations, shelters, community-based organizations, local governments, and social service agencies to identify and address housing-related and other social drivers of health. The CHW serves as a trusted liaison between patients, healthcare teams, and community resources, helping individuals navigate complex healthcare, housing, and social service systems.
The CHW supports individuals across the continuum of housing instability, including those who are unsheltered, residing in emergency or temporary shelter, living in transitional housing, experiencing unstable or inadequate housing, facing eviction or displacement, or otherwise at risk of homelessness. The CHW works to reduce barriers to healthcare and promote housing stability by connecting individuals with appropriate housing programs, healthcare services, behavioral health resources, public benefits, food and transportation assistance, and other essential community supports.
The Community Health Worker conducts outreach, completes comprehensive social needs assessments, assists with resource applications and enrollment, coordinates referrals, and provides ongoing follow-up to facilitate successful connections to services. The CHW works closely with community partners to support closed-loop referrals and identify barriers that may prevent patients from accessing or maintaining needed resources.
The CHW gathers, validates, documents, and utilizes information from the electronic medical record (EMR), Social Drivers of Health (SDOH) screening tools, social care referral platforms, and other identified data systems to support patient care, grant reporting, program evaluation, quality improvement, and health equity initiatives.
This position operates within a hybrid model and requires flexibility to engage individuals where services are most accessible. Work may occur within MUSC clinical and hospital settings, shelters, community organizations, outreach locations, and other community-based settings throughout Charleston, Berkeley, and Dorchester Counties. Telephonic, electronic, and remote outreach and care coordination are also required.

Entity

Medical University Hospital Authority (MUHA)

Worker Type

Employee

Worker Sub-Type​

Temporary

Cost Center

CC005264 SYS - Pop Health - CHAI Grant

Pay Rate Type

Salary

Pay Grade

Health-24

Scheduled Weekly Hours

40

Work Shift

Job Description

The Community Resource Navigator: Community Health Worker – Housing & Homelessness is a grant-funded position that reports to the Program Director of Community Navigation within MUSC's Population Health Department. This position is dedicated to providing outreach, navigation, advocacy, and care coordination for individuals experiencing housing insecurity or homelessness throughout the Tri-County region (Charleston, Berkeley, and Dorchester Counties).

The Community Health Worker (CHW) works collaboratively with patients, healthcare providers, interdisciplinary care teams, housing organizations, shelters, community-based organizations, local governments, and social service agencies to identify and address housing-related and other social drivers of health. The CHW serves as a trusted liaison between patients, healthcare teams, and community resources, helping individuals navigate complex healthcare, housing, and social service systems.

The CHW supports individuals across the continuum of housing instability, including those who are unsheltered, residing in emergency or temporary shelter, living in transitional housing, experiencing unstable or inadequate housing, facing eviction or displacement, or otherwise at risk of homelessness. The CHW works to reduce barriers to healthcare and promote housing stability by connecting individuals with appropriate housing programs, healthcare services, behavioral health resources, public benefits, food and transportation assistance, and other essential community supports.

The Community Health Worker conducts outreach, completes comprehensive social needs assessments, assists with resource applications and enrollment, coordinates referrals, and provides ongoing follow-up to facilitate successful connections to services. The CHW works closely with community partners to support closed-loop referrals and identify barriers that may prevent patients from accessing or maintaining needed resources.

The CHW gathers, validates, documents, and utilizes information from the electronic medical record (EMR), Social Drivers of Health (SDOH) screening tools, social care referral platforms, and other identified data systems to support patient care, grant reporting, program evaluation, quality improvement, and health equity initiatives.

This position operates within a hybrid model and requires flexibility to engage individuals where services are most accessible. Work may occur within MUSC clinical and hospital settings, shelters, community organizations, outreach locations, and other community-based settings throughout Charleston, Berkeley, and Dorchester Counties. Telephonic, electronic, and remote outreach and care coordination are also required.

Responsibilities:

1. Collaborates with patients, family members/caregivers, healthcare professionals and community-based organizations to address social care needs and socio-economic barriers to health

2. Conducts screening and assessments to identify appropriate resources for patients being seen by the Palliative Care and Geriatrics teams living with serious illness to assist with their unmet social, medical, and behavioral needs and facilitates assistance or interventions between care visits

3. Provides education and information about available community resources and services to Palliative Care and Geriatrics patients and family members/caregivers

4. Builds relationships with Palliative Care and Geriatrics patients and community-based organizations and follows up to close the loop and ensure needed services are received

5. Assists with social care program enrollment forms and applications for high-risk patients and follows up to close the loop and ensure needed services are received

6. Gathers information, documents, and enters data into the electronic medical record, social care electronic platforms and other identified tools and contributes to data analysis

7. Summarizes progress to leadership team on a regular basis to keep them aware of the success and to engage them in quality initiative/improvement process

Requirements (Education, Work Experience, Licensure, Registry and/or Certifications, and a plus if Bilingual - Spanish speaking/preferred)

· Bachelor's degree in public/community health/social work

OR

· Associate degree in public/community health or healthcare related field with a minimum of one (1) year of experience in a directly related field or working in a community-based setting including paid or volunteer activity with a non-profit organization, church, healthcare organization, neighborhood community center, or other relevant community-based involvement.

· Completion of SCCHW Certification within (1) year of hire: https://www.scchwa.org/credentialing-information-learners and/or other Community Health Worker training course.

· Valid driver’s license, an acceptable 3-year motor vehicle as defined by the Acceptable Motor Vehicle Record (MVR) Chart, and a certificate of auto-insurance.

AND

Good organizational and time-management skills

Ability to work independently with accountability and exercise sound judgment, discretion and professionalism at all times.

Available to work occasional evenings and weekends.

Ability to travel and independently meet with patients in the clinic, home or community-based setting.

Physical Requirements

Ability to perform job functions while standing. (Continuous) Ability to perform job functions while sitting. (Continuous) Ability to walk. (Frequent) Ability to climb stairs. (Infrequent) Ability to work indoors. (Continuous) Ability to work outside in temperature extremes. (Infrequent) Ability to kneel. (Infrequent) Ability to bend at the waist. (Infrequent) Ability to twist at the waist. (Infrequent) Ability to squat. (Infrequent) Ability to reach. (Frequent) Ability to lift/carry 15 lbs. unassisted. (Frequent) Ability to lift/lower objects 15 lbs. from/to floor from/to 36 inches unassisted. (Infrequent) Ability to lift from 36 inches to overhead 15 lbs. unassisted. (Infrequent) Ability to move objects from floor level to 36