Optimus Health Care, Inc.·Bridgeport, Connecticut
Conduct community-based outreach and care navigation for justice-involved individuals to improve linkage to primary care and behavioral health services. Provide health education, social drivers of health support, and coordination with reentry stakeholders like the Department of Correction and shelters.
Join a Team That Makes a Difference at Optimus Health Care!
Are you passionate about providing high-quality, patient-centered care? Optimus Health Care—the largest provider of primary health care services in Fairfield County—is looking for dedicated professionals to join our team! With multiple locations in Bridgeport, Stratford, and Stamford, our mission is to be a lifelong health care partner, dedicated to achieving optimal wellness for the communities we serve.
Optimus Healthcare is looking for a full-time transitions clinic community health worker with outreach experience to join our team in Bridgeport CT. This position i requires local travel between sites and facilities. Working knowledge of Spanish is strongly preferred.
The Transition Clinic Community Health Worker is a 100% grant-funded, non-exempt position responsible for community-based outreach, reentry care navigation, patient engagement, health education, social drivers of health support, and care coordination assistance for individuals recently released from incarceration or otherwise justice-involved who are connected to Optimus Health Care and the Bridgeport service area.
The role supports statewide reentry coordination for individuals released from Connecticut Department of Correction facilities or other justice-related settings who are expected to receive, continue, or establish care through Optimus Health Care. The CHW works as part of an interdisciplinary Transition Clinic team and collaborates with primary care, behavioral health, nursing, care coordination, substance use treatment, community partners, DOC contacts, halfway houses, shelters, and other reentry stakeholders.
The position is designed to improve timely linkage to care, appointment attendance, retention in care, medication access, chronic disease management, behavioral health, and substance use linkage, harm reduction support, and stabilization after release. The role is non-clinical and does not replace licensed medical, behavioral health, or case management functions; however, it is essential to patient engagement, trust-building, navigation, advocacy, and follow-through.
Essential functions & responsibilities
1.
Conduct outreach, engagement, and navigation for individuals recently released from incarceration or otherwise justice-involved who have chronic medical, behavioral health, substance use, and social needs.
2.
Support statewide reentry coordination for patients released from Connecticut DOC facilities or other justice-related settings when they are connected or expected to link to Optimus/Bridgeport services.
3.
Conduct in-reach/outreach inside DOC facilities when permitted by DOC, Optimus policy, grant scope, facility requirements, and supervisor approval.
4.
Coordinate with DOC contacts, halfway houses, shelters, reentry programs, probation/parole contacts when appropriate, and community partners to identify eligible patients and support continuity of care.
5.
Recruit and engage eligible patients for the Transition Clinic program using program-approved outreach workflows and referral pathways.
6.
Assist patients with linkage to Optimus primary care and related services, including appointment scheduling, appointment reminders, visit preparation, warm handoffs, and follow-up after missed visits.
7.
Support care coordination for priority health areas, including HIV, hepatitis C, diabetes, hypertension, substance use disorder, mental health, medication access, preventive care, and primary care linkage.
8.
Provide health education and self-management support using non-clinical, culturally responsive, trauma-informed, and patient-centered approaches.
9.
Use motivational interviewing, harm reduction principles, and nonjudgmental communication to support patient goals, engagement, and readiness for care.
10.
Provide harm reduction and recovery support, including overdose prevention education, naloxone education/referral, MOUD/Sublocade linkage support, relapse-prevention encouragement, and referral to substance use treatment as appropriate.
11.
Assist with social drivers of health screening and stabilization needs, including Medicaid/HUSKY access, SNAP, identification documents, housing referrals, employment resources, food, clothing, phone access, transportation resources, and medication access.
12.
Coordinate transportation resources for appointments and services, including identifying barriers, helping patients schedule rides, confirming pickup and appointment logistics, and documenting transportation needs.
Direct patient transportation is not routine and may occur only when approved by the program, supervisor, and Optimus policy.
13.
Make referrals and warm handoffs to community resources and follow up to support connection, completion, and problem-solving when barriers arise.
14.
Document outreach, patient contacts, referrals, barriers, follow-up, and care coordination activities in EPIC and/or other approved systems in a timely manner according to Optimus policy and program standards.
15.
Maintain recruitment logs, linkage outcomes, appointment attendance support, referral follow-up, outreach activity, patient engagement updates, and other program-defined grant tracking data.
High school level education; Two years of related work experience and an associate’s degree; or a bachelor’s degree in a related field; or an equivalent combination of experience and education.
Bilingual English/Spanish strongly preferred. Ability to communicate with patients, staff, and community partners using tactful, culturally responsive, trauma-informed, and nonjudgmental communication in sensitive or emotional situations.
Community Health Worker certification preferred but not required. If not already certified or trained as a CHW, willingness and ability to complete CHW training within the first 90 days of employment or within the timeframe approved by the supervisor.
Valid and verifiable Connecticut driver’s license, good driving record, and reliable transportation required.
Ability to travel to Optimus sites, approved community locations, halfway houses, shelters, partner agencies, and DOC facilities when permitted and required.
Ability to meet requirements for entry into DOC facilities and partner sites when applicable, including background checks, facility orientation, security clearance, and site-specific protocols.
Ability to complete required Optimus, grant, compliance, safety, HIPAA, and program trainings.
OHC provides a fun, fast-paced working environment, where our commitment to quality is present in every job function.
Excellent health & welfare benefit options
Competitive Compensation
Optimus and its caring, multilingual staff proudly serve our community in a patient-centered environment.
Optimus is committed to providing equal employment opportunities to all applicants and employees as protected by applicable federal and/or state law.
Market context
Community health worker roles in Connecticut are often tied to care coordination, outreach, and support for patients moving between settings, so employers commonly look for candidates with strong communication skills and local community experience. This role is competitive because a high school diploma is required, while an associate or bachelor’s degree, CHW certification, and outreach or human services experience can strengthen an application; a valid Connecticut driver’s license and reliable transportation are mandatory. Review the AI-summarized requirements and benefits here to save research time, then tailor your application to show direct patient support and community outreach experience.