Community Health Worker (Bilingual English/Spanish)

The Community Health Worker (CHW) operates within the New Mexico Department of Health (NMDOH) Community Health Worker Scope of Work and plays an essential role in connecting families with ABA services, supporting client engagement, and fostering community partnerships.

The CHW provides culturally responsive outreach, coordination, and family-centered education so that every family has the support they need to begin and sustain services with FronteraCare.

The CHW serves as the primary intake representative for an assigned group of families, providing consistent support and communication from initial referral through completion of the intake process. They partner closely with the Intake and Scheduling teams to help families move smoothly toward evaluation and service start, making sure no one gets lost between referral and the first appointment.

Beyond intake, the CHW provides ongoing case management for these families. This means understanding each family’s needs, connecting them with community resources, and building trusting relationships that continue well after services begin.

Intake & Referral Coordination

• Serve as the primary intake representative for an assigned group of families, providing consistent communication and support from initial referral through completion of the intake process.
• Conduct proactive outreach and follow-up with new leads and referrals — via calls, texts, and emails — to reduce backlog and help families move from initial inquiry toward evaluation scheduling.
• Partner with Intake Specialists, the Family Intake Coordinator, and Care Liaison to coordinate evaluation scheduling, required documentation, and next steps for assigned families.
• Help families understand what to expect during the intake process, including evaluations, required documentation, and timelines.
• Track intake progress for assigned families and flag delays or barriers to the Intake team.

Case Management

• Serve as the ongoing point of contact for assigned families once intake is complete, continuing the relationship built during referral and onboarding.
• Conduct monthly outreach to each assigned family to check in on how services are going and how the family is doing overall, including factors beyond therapy that may affect their engagement and stability.
• Identify barriers facing each family, such as housing, food security, transportation, financial hardship, and emergency needs, and connect them with community, state, and local resources.
• Follow up on referrals and resource connections to confirm families received the support they need, and adjust as circumstances change.
• Provide timely support between scheduled check-ins as needs arise.
• Partner with the care team and Care Liaison to address non-clinical barriers to care, including attendance and access challenges, and share relevant family context to support service continuity.
• Help families navigate insurance and benefits, including Medicaid reapplication and coverage changes that could interrupt services.
• Document all family contacts, identified needs, referrals, and follow-up in accordance with organizational and NMDOH CHW standards.

Clinical Quality

• Coordinate client referrals, assessments, and onboarding for families on FronteraCare’s waitlist.
• Support families in understanding the ABA process, clinical goals, and care expectations.
• Assist with ongoing service coordination, including client scheduling and follow-up support.
• Engage families who have paused services or experience frequent cancellations to identify and address barriers to care.
• Promote adherence to treatment recommendations and consistent participation in services.
• Operate within NMDOH Community Health Worker Scope of Work, contributing to:
• Community outreach and engagement
• Care coordination and case management
• Home-based and community support
• Health promotion, training, and system navigation

Professional and Ethical Conduct

• Maintain confidentiality, discretion, and professional boundaries in all interactions with clients and colleagues.
• Follow all Frontera Health policies and applicable state and federal regulations.
• Demonstrate integrity and ethical behavior consistent with NMDOH CHW standards and ABA service expectations.
• Uphold a strengths-based, family-centered approach in all work.
• Accurately document all outreach, case coordination, and family interactions.

Communication and Family Interaction

• Serve as a trusted liaison between FronteraCare, clients, and community partners.
• Provide clear, empathetic, and culturally responsive communication to families.
• Educate families on the benefits of ABA therapy, service processes, and available community resources.
• Support families through changes in service status (e.g., on hold, paused services, or new onboarding).
• Reinforce family understanding of care plans and encourage collaboration with clinical staff.
• Facilitate translation and interpretation as needed to enhance understanding and engagement.
• Support full alignment with FronteraCare’s technology platforms, including assessment tools and digital phenotyping systems; ensure families are actively engaged in providing consent, using the parent training app, and understanding video-based technology.
• Utilize technology to enhance family engagement, monitor adherence to digital protocols, and identify opportunities for additional guidance or support.

Leadership and Mentorship

• Model professionalism, collaboration, and accountability for other team members.
• Promote a positive, solutions-focused clinic culture aligned with Frontera Health’s values.
• Serve as a resource for families and staff on community systems and service navigation.
• Participate in meetings, parent training, and team discussions to enhance care coordination and service delivery.
• Demonstrate proactive problem-solving and communication to address client and family needs

Qualifications and Requirements

Required:

• Community Health Worker Certification from the NMDOH Office of Community Health Workers
• Bilingual in English and Spanish for effective family communication
• Organization & task management skills to ensure families are being wholly supported and following up consistently through the care initiation journey 
• Empathy to support families through challenging situations 
• Patience to support families through complex care coordination & navigation activities

 

Preferred:

• Experience working with families or children in health, social services, or behavioral health settings
• Excellent communication, interpersonal, and organizational skills
• Knowledge of community health systems and social service resources
• MSW or LCSW candidates are strongly encouraged to apply (not required)
• Experience with intake coordination, lead follow-up, or scheduling in a healthcare or behavioral health setting

Work Environment and Travel

• Hybrid schedule: approximately 75% remote / 25% travel within FronteraCare New Mexico regions
• Travel may include home visits, community outreach events, and care coordination meetings
• Occasional evening or weekend work may be required based on family or program needs