Community Health Worker at Sabathani… · Minneapol…

Sabathani Community Center (SCC) is one of Minnesota’s oldest African American-founded nonprofits & serves a multi-cultural community of more than 50,000 community members in South Minneapolis. SCC was founded in 1966 by a handful of concerned community members seeking to address social and economic disparities in underserved communities in the areas of youth programming, housing, health and education. The organization is a major resource hub expanding services within the South Minneapolis community. Learn more at www.sabathani.org.

To perform this job successfully, you must be able to carry out each essential job function satisfactorily.

About the role

Sabathani Community Center's Health Equity Department works to reduce health disparities and improve access to care for community members through direct service, care coordination, and community education. The department's programming is designed to meet residents where they are, with a focus on culturally responsive, trauma-informed care.

Maternal Health Matters (MHM) is Sabathani's culturally grounded program supporting Black/African American families throughout pregnancy and the postpartum period. The program pairs participants with a Community Health Navigator for individualized case management and connection to care and offers a weekly Sister Support Circle, prenatal yoga, social programming like Mommies and Mocktails, and peer support in a culturally affirming space. MHM was built to address the social and emotional factors that most impact maternal and infant health outcomes, meeting families where they are and walking alongside them from pregnancy through the first year postpartum.

Sabathani Community Center is seeking a Community Health Worker to provide direct case management, care coordination, and social determinants of health (SDOH) support to Black/African American pregnant and postpartum community members enrolled in an integrated care program. The Community Health Worker carries a caseload of approximately 15 participants, providing individualized support from enrollment through pregnancy and 12 months postpartum. This role builds trusted relationships with participants, connects them to clinical, behavioral health, and social service resources, and works alongside doulas, mental health providers, and program leadership to ensure participants and their families are well supported.

The physical duties associated with this position are consistent with duties associated with work performed in an office and community setting, including home visits. This job description serves only as a general description of the anticipated day-to-day responsibilities of the position. This document does not create an employment contract, implied or otherwise, other than an "at will" employment relationship. The Director of Health Equity retains the discretion to add duties or change the duties of this position at any time.

What you'll do

Intake, Screening & Planning

● Administer PRAPARE (social determinants of health), 4Ps (substance use), and EPDS (depression) screenings for all newly enrolled participants.

● Develop an individualized care plan with each participant within 30 days of enrollment.

● Maintain a caseload of approximately 15 participants, providing consistent, relationship-based support.

● Document all screening results and encounters in Salesforce within 48 hours.

Ongoing Participant Support

● Conduct weekly participant check-ins by phone, home visit, or in person throughout pregnancy and the postpartum period.

● Provide at least one home visit per month for participants identified as high-risk.

● Rescreen participants using EPDS at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months postpartum.

● Maintain contact with participants through 12 months postpartum, facilitating referrals for interconnection care, family planning, primary care, and chronic disease management.

Referrals & Care Coordination

● Maintain an up-to-date resource directory of culturally responsive health, behavioral health, substance use, housing, food, and social service providers.

● Facilitate warm referrals and follow up with participants and providers within 72 hours of referral.

● Track referral completion and coordinate with child welfare per written protocol when substance use and welfare involvement intersect.

● Coordinate with doulas, the contracted mental health provider, and other program partners to ensure participants receive integrated, wraparound support.

Basic Needs & Social Determinants of Health Support

● Assess transportation, housing, and basic needs at intake and on an ongoing basis.

● Distribute transportation assistance (rideshare/gas cards) and connect participants to utility and rent assistance as needed.

● Distribute basic needs provisions (breast pumps, diapers, formula, infant carriers) at birth and coordinate postpartum Meal Train support.

● Document all client assistance and provisions provided in Salesforce.

Education & Community Engagement

● Deliver 1:1 participant education on nutrition, breastfeeding, infant safe sleep, reproductive life planning, and postpartum wellness.

● Support and participate in the annual Baby Shower and Health Fair and other community events.

● Document all education encounters by date, topic, and participant in Salesforce.

Documentation & Compliance

● Enter all program data in Salesforce within 48 hours of each participant encounter.

● Participate in monthly reflective supervision and monthly data reviews with program leadership.

● Support grant reporting by ensuring documentation is accurate, complete, and submitted on time.

Qualifications

Education:

● High school diploma or equivalent required.

● Community Health Worker (CHW) certification required.

● Associate's or Bachelor's degree in a related field a plus but not required.

Experience:

● Minimum 2-years of experience in community health, case management, doula work, or a related direct service role.

● Experience working with pregnant and postpartum Black/African American community members strongly preferred.

● Experience with client documentation and case management systems (Salesforce experience a plus).

● Lived experience and cultural connection to the community served is highly valued.

Knowledge, Skills and Abilities:

● Ability to build trust and maintain strong, culturally responsive relationships with participants and families.

● Working knowledge of maternal and infant health, social determinants of health, and community resources in the Twin Cities metro area.

● Strong organizational skills with the ability to manage a caseload, meet documentation deadlines, and coordinate across multiple partners.

● Ability to communicate clearly and effectively via oral and written means.

● Ability to maintain appropriate boundaries and exercise sound, independent judgment, including in emotionally sensitive situations.

● Working knowledge of Outlook, Word, and Excel; experience with Salesforce or similar case management systems a plus.

Licenses and/or Certifications:

● Community Health Worker (CHW) certification required.

● Valid MN Driver's License and access to reliable transportation required for home visits and community-based work.

● Must pass a criminal background check.