Community Health Worker, Care Management
: Job Details :

Title: Community Health Worker, Care ManagementReports to: Manager of Care ManagementClassification: Individual ContributorLocation: Western, MAJob description revision number and date: V 3.0; 11.4.2024Organization Summary:Community Care Cooperative (C3) is a 501(c)(3) non-profit, Accountable Care Organization (ACO)governed by Federally Quality Health Centers (FQHCs). Our mission is to leverage the collectivestrengths of FQHCs to improve the health and wellness of the people we serve. We are a fast-growingorganization founded in 2016 with 9 health centers and now serving hundreds of thousands ofbeneficiaries who receive primary care at health centers and independent practices acrossMassachusetts. We are an innovative organization developing new partnerships and programs toimprove the health of members and communities, and to strengthen our health center partners.Job Summary:As an integral member of the care management team the Community Health Worker (CHW) will havethe opportunity to make a profound impact on the lives of people living with complex and/ orchronic conditions, many of whom also face multiple barriers accessing care and need support tosucceed with achieving health care goals. This position requires flexibility and may vary fromday-to-day to meet members where they are. Outreach methods may vary based on the needs of theorganization and may include telephonic or in person in a variety of potential settings such as butnot limited to, the community, home, facility, or health center. This role is hybrid and willrequire health center, medical/BH hospital facility, community, or home-based work.Responsibilities:* Works under the guidance of the Licensed Care Manager or Program Leaders (Leads,Supervisor,Manager or Director)* Conducts initial outreach calls to encourage member/representative and caregivers to participatein care management programs* Develop and implement outreach plans in collaboration with team colleagues, based on individual,family, and community needs, strengths and resources* Identify and share appropriate information, referrals, and other resources to help individuals,families, groups and the primary care team meet their needs* Gather and combine information from different sources to better understand clients, theirfamilies and communities* Initiate and sustain trusting relationships with individuals, families, social networks andprimary care team* Use a range of outreach methods to engage individuals and groups in diverse settings* Share community assessment results with colleagues and community partners to inform planning andhealth improvement efforts* Use effective communication skills* Act as a cultural mediator by educating and supporting providers in working with clients fromdiverse cultures and help clients and community members interact effectively with professionals topromote health, improve services, and reduce health care disparities* Addresses language and cultural barriers to care* Coaches and guides member/representative to meet both personal and clinical goals* Assists in scheduling appointments on behalf of member/representative* Work with individuals, family, community members, primary CM and primary care team to addressissues that may limit opportunities for healthy behavior. This includes completing Social Driversof Health (SDOH) screen and other tactics to obtain barriers to care* Provide care coordination, which may include but not limited to facilitating care transitions,supporting the completion of referrals, and providing or confirming appropriate follow-up* Help bridge cultural, linguistic, knowledge and literacy differences among individuals,families, communities, and providers* Helps member/representative access community and government-based service agencies includingcompleting paperwork for the member* Helps teach the member/representative and/or care giver about symptom response plans* Participates in the integrated care team meetings and rounds as required* Complies with reporting, record keeping, and documentation requirements in one's work* Use appropriate technology, such as computers, for work-based communication according to C3 andhealth center requirements* Creates and maintains a comprehensive inventory of local community resources, improvingaccessibility for patients and providers, and linking patients with the appropriate supportservices* Establishes relationships with community agencies, resources and supports that are relevant to aMedicaid Population* Assist with Medicaid applications, food, and nutrition benefits, housing applications,coordinating transportation, etc.* Travel throughout assigned area and engage members at their homes/ hospitals/community-basedlocations and or accompany members to appointments as appropriate* As needed, cover other areas in person or via telephonic support* Other duties as assignedDesired Other Skills:* Demonstrated success in working as part of a multi-disciplinary team including communicating andworking with Providers, Nurses, Social Workers, and other health care teams* Bi-lingual (preferred)* Experience with anti-racism activities, and/or lived experience with racism is highlypreferred* Experience working with patients with chronic medical and behavioral health needs* Experience working with Medicare, Medicaid and/or Special Needs populations* Must be flexible and adaptable to change* Demonstrate the ability to work independently* Must demonstrate excellent interpersonal communication skills* Additional desirable qualities include enthusiasm and passion for helping patients, genuinespirit,kind, and empathetic nature, and one who embraces a 'go with the flow' mentality* Experience using appropriate technology, such as computers, for work-based communication,according to organizational requirements* Experience and proficiency with Microsoft Office and online record keepingQualifications:* Experience within the ACOs member population preferred including Medicare/Medicaid* Medical Assistant, Engagement Specialist or Community Health Worker Certification* A valid driver's license and provision of a working vehicleIn compliance with Covid-19 Infection Control practices per Mass.gov recommendations, werequire all employees to be vaccinated consistent with applicable law.