Community Health Worker, Care Management - Florence
: Job Details :

About UsWith energy and purpose, Cooley Dickinson Health Care, an affiliate of Mass General Brigham, is advancing health care in western Massachusetts. With a broad network of providers and facilities serving the Pioneer Valley, our services span a spectrum of medical and surgical needs, diagnostic care, rehabilitation, social work, behavioral health, and other critical needs of the community.The Cooley Dickinson culture is built on living the values of our organization. Every employee is valued, no matter what professional function. Come work where you can make a difference every day, with opportunities for growth and development, in a great place to call home!Role OverviewWe are seeking a full-time, 40-hour Community Health Worker (CHW) to join our team supporting the Integrated Care Management Program (iCMP)! This is a hybrid opportunity, with a schedule of Monday-Friday 8:30am-5:00pm. On Tuesdays, the CHW will typically be in office at 10 Main Street in Florence, MA, and the other 4 days of the week would be remote work and travel as needed to meet with our patients out in the community areas of Amherst, MA and Greenfield, MA. The CHW will need reliable transportation to meet these travel needs. The schedule can be flexible depending on the department's and patient's needs.The CHW collaborates with the care team to enhance the iCMP system and ensure patients of all ages receive the comprehensive care they need. The CHW works closely with families to help them navigate health and mental health care systems, community services, advocating for the patient and teaching them how to access necessary resources. They support families in organizing and following through with health-related tasks, managing a caseload of approximately 25-30 patients alongside an RN/SW Care Manager. The CHW focuses on improving patient and family experiences and ensuring high-quality care by addressing needs efficiently and continuously optimizing the care process.The position requires a high degree of flexibility, independence, and willingness to participate in multiple initiatives and provide support to all members of the care team. The position requires strong communication skills and the ability to converse comfortably with patients and their caregivers, practice staff and program staff.Essential Job Functions:* Build individual and team capacity* Involve participant in self and community advocacy* Map communities to help locate support services (i.e. housing, food, shelter, community services, etc.), working closely with the iCMP Community Resource Specialist to achieve this and educate other team members on resources found* Connect families with needed resources, including tracking referrals when appropriate* Assist patients and families in applying for State resources and services (i.e. Mass Health, DTA, DDS, and DMH). This may include helping them gather necessary documentation, filling out forms, and helping them anticipate and prepare for re-applications when needed* Follow up with families on status of applications* Locate and coordinate services for children with Autism (i.e. ABA therapy, social skills groups, camps, in-home supports)* Locate mental health providers within a patient's insurance network and collaborate with PCP and iCMP Team on ensuring referrals to appropriate providers* Attend meetings regarding educational and mental health services for patient* Support families in advocating for services. Attend 504/IEP meetings with families. Coordinate with iCMP Care Team and PCP meeting details and next steps* Attend meetings with patient/family in the community. Provide updates to iCMP SW/CM and PCP* Provide peer support to families struggling with behavioral health issues* Assist with cultural mediation between communities and health and human services systems* Provide culturally appropriate health education* Make follow up calls and home visits when needed to patients and families.* Assist patients with organizing their records and making follow up appointments* Document patient encounters in electronic medical record* Attend weekly supervision and team meetings* Develop and maintain strong working relationships with iCMP Social Workers, iCMP Nurse Care Managers, primary care providers, etc.* Perform other functions/duties as requestedQualificationsWhen hiring, we look for candidates who possess not only the relevant skills and competencies, but also positive attitudes, emotional intelligence, and genuine passion for this work.* High school diploma or equivalent preferred; relevant experience in the community or Associates Degree required; Bachelor's Degree preferred* Strong understanding of psychiatric and family system and ability to use this understanding to formulate succinct case summaries required* Good organizational and time management skills and the ability to set up systems to help others with these skills required* Strong interpersonal skills enabling effective team collaboration required* Demonstrated ability to be flexible and adapt to a complex, fast-paced medical environment required* 1-2 years of prior experience working with patients and families dealing with complex medical and psychiatric/behavioral problems; the ability to help patients and families/caregivers understand and access the resources required to support care, ideally with experience in private/public educational systems, community mental and behavioral health centering on holistic patient and family care required* Bilingual preferred* Experience as a community health worker, peer specialist, peer advocate, or a similar role preferred; firsthand or secondhand experience dealing with behavioral health issues, navigating the behavioral health care system, and/or navigating the special education system in Massachusetts preferred* Strong computer skills and use of Microsoft Word/Excel/Outlook required; experience with electronic medical records preferred