Senior Community Health Worker ("CHW")

Job Type

Full Time




349 East 149th Street, Suite 405
United States


The Opportunity

a.i.r. nyc is a high impact community-based organization providing care coordination services in the home setting to children and adults. Since 2001 we have focused on patients with poorly controlled asthma, consistently demonstrating results by significantly reducing avoidable hospital admissions, avoidable ED visits, and school absenteeism due to asthma.


Addressing social determinants of health is a major component of a.i.r. nyc’s home-based care coordination model and we are expanding our services in 2018 to help families address diabetes, hypertension, depression and anxiety, as well as challenges related to aging, all of which disproportionally affect vulnerable New Yorkers.


At this moment of organizational transformation, a.i.r. nyc is seeking a Senior Community Health Worker to provide direct-services in homes and in communities for patients self-managing chronic disease. The Senior CHW will have the capabilities and empathic approach required to work with patients and their caregivers, navigate referrals to supportive social services, communicate with referring providers, manage data and technology, and assure the highest level of quality and effectiveness in helping families connect the dots within a fragmented health care delivery system. New York City's most vulnerable families face many challenges – including poverty, unemployment, racism, language barriers, poor housing conditions, homelessness and lack of access to social services. We are looking for someone with a passion for helping New Yorkers address these challenges and break the revolving cycle of poverty that is worsened by chronic disease.



Senior Community Health Worker Position Summary

The central, driving task for this direct-service position is to provide home-based care for patients with one or more chronic diseases and motivate patients to take steps towards healthy self-management. The Senior CHW will also play a lead role in programmatic design by collaborating with the a.i.r. nyc leadership team to refine, optimize, and operationalize our new interventions for diabetes, hypertension, anxiety, depression, and challenges related to aging. In addition to program design, the Senior CHW will be actively involved in the deployment of technology, such as mobile apps and software, to improve patient engagement, care coordination, performance monitoring and reporting to stakeholders.


The Senior CHW must be fluent in both English and Spanish. Interpersonal skills for moral support and motivation are required. The Senior CHW must be able to motivate and inspire patients and families to be proactive in developing the skills and practices for self-directed care of chronic diseases. The Senior CHW reports to the Director of Care Coordination.


In collaboration with a.i.r. nyc’s care team, you will:

  • Provide home-based care for patients with chronic diseases, including asthma, diabetes, hypertension, anxiety, depression, and challenges associated with aging
  • Participate in program development and implementation of a.i.r. nyc’s new interventions as the organization expands beyond its current model for home-based asthma care
  • Become an adept user of our case management system (Salesforce) and other technology including mobile apps and other software that supports patient engagement and data collection
  • Coordinate care among members of the care team that might include referring clinical partners, a.i.r. nyc staff, and community partners providing supportive services
  • Help families adopt health seeking practices toward wellness and self-directed care by supporting patients in the co-creation and monitoring of care plans to improve health outcomes
  • Provide culturally appropriate and accessible health education and information in the home setting
  • Educate and motivate patients and their families on the importance of lifestyle changes and on adherence to their medication regimens and recommended treatments, and finding ways to increase adherence to medications
  • Administer health screening tools, conduct baseline and follow up assessments of health and environmental status of the homes of participating children and their caregivers
  • Connect patients with supportive services that are aligned with their particular care regimen, such as: nutritional programs, smoking cessation services, or legal assistance
  • Provide information on available levels of service including how to navigate the local healthcare system
  • Remain in frequent contact with families to check in on general health status, forging relationships over a one-year period or longer, if needed
  • Provide accurate and timely documentation of home visits, including clear, thorough, and concise visit notes


Typical Working Conditions

  • Home visits are performed in the homes of our patients and sometimes meetings are held
  • Requires daily local travel to homes throughout NYC (not Staten Island at present)
  • Additional duties in the office include, but are not limited to data management, quality control, and case reviews, trainings, meetings
  • Frequent contact with staff and other stakeholders (e.g., families, referring agencies, community professionals, community agencies / programs)

Required Qualifications

  • Passionate about helping families across New York City break the revolving cycle of poverty that is worsened by chronic disease
  • Bilingual Spanish/English, with strong verbal and writing skills in both languages
  • Master’s degree in Public Health, Health Education, Social Work, or related field
  • Strong communication and interpersonal skills; must be a team player and have a sense of humor
  • Ability to work with agility, flexibility, and clear communication during a period of program development and implementation
  • Experience planning and delivering health education—in group and individual settings
  • Strong organizational skills; ability to manage a large caseload of families and efficiently and consistently produce quality work
  • Highly comfortable using technology on a day-to-day basis
  • Capacity to anticipate and solve problems
  • Flexibility with the changing needs and schedules of families; ability to work occasional Saturdays

 Desirable Qualifications

  • Experience providing home-based services
  • Experience working with people with asthma, diabetes, hypertension, behavioral health (depression and anxiety), as well as challenges related to aging
  • Familiarity with New York City hospitals and healthcare delivery system
  • Experience using a database including the ability organize, enter, and report on data collected
  • Training in Motivational Interviewing (MI)
  • Salesforce, Outlook and Excel experience an asset, but not required


Excellent benefits provided, including health, dental, 401k, and monthly MTA pass. a.i.r. nyc staff members are employees of the Fund for The City of New York (FCNY). FCNY is an equal opportunity employer.  

Professional Level

None specified

Minimum Education Required

Master's degree

How To Apply

Please submit a cover-letter and resume via email to: with the subject: "Senior CHW application"