Job Description

Job Title: Community Health Worker (CHW) – LTSS & Care Transitions

Position Summary:
We are seeking a Community Health Worker (CHW) to support older adults and adults with disabilities in Rhode Island to remain safely in the community and to transition from hospital or nursing facility settings back to home. This role focuses on navigation of Medicaid Long-Term Services and Supports (LTSS), coordination with discharge planners, and connection to Home and Community-Based Services (HCBS).

Key Responsibilities:

• Partner with hospital discharge planners, homecare teams, and SNF interdisciplinary teams to support safe discharge planning
• Assist individuals in accessing Rhode Island Medicaid LTSS programs, including HCBS and waiver services
• Address social determinants of health (housing stability, food access, transportation, utilities)
• Connect clients to local community resources, including aging and disability service organizations
• Collaborate with Managed Care Organizations (MCOs), care managers, primary care providers, behavioral health providers, and social workers
• Maintain accurate, timely documentation consistent with RI Medicaid and program requirements
• Track outcomes related to transitions, service linkage, and community tenure

Qualifications:

• High school diploma or equivalent required;
• RI CHW certification through RI Certification Board required
• Experience working with older adults, individuals with disabilities, or in healthcare/social services
• Experience with RI Medicaid waiver programs and eligibility processes
• Knowledge of PASRR considerations and nursing facility level of care criteria
• Experience coordinating with SNFs, including discharge planning and post-acute care transitions
• Bilingual (Spanish or other languages common in RI communities)

EOE

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