Community Health Workers - South Shore

  • Uses internal and external resources (such as referrals, chart review and pharmacy data) to identify accurate, successful modes of communication for initial patient engagement. - Outreach to and engage providers in research efforts, as needed. - Outreach directly to patients. - Utilizes communication skills such as motivational interviewing to gain agreement from the patient to participate and be receptive to the iCMP Plus Program. - Provides education to new patients regarding iCMP Plus and the role of the Care Partner and Care Team. - Maintains appropriate written and oral communication on a timely basis, completing documentation within 48 hours and returning non-urgent calls within 48 hours. - Will engage in regular assessments (HRA, LTSS) pertaining to Social Determinants of Health (SDOH). - Conduct regularly scheduled visits to ensure that patient’s medical, behavioral and social needs are addressed. - Support the health education needs of the patient in collaboration with the Care Partner, Behavioral Health Specialist and PCP. - Works toward the promotion, prevention, and reduction of health risks. - Identify gaps pertaining to SDOH which influence barriers to patients care and influence unmet needs. - Coordinate with the Care Partner along with the PCP and iCMP Plus inter-professional care team to identify areas of opportunity, as well as defined resources. - Responsible for assessing health risks, completes health risk assessment (HRA). - Provide input to patients care team on key care management/care coordination decisions. - Coordinate appointments for patients with multiple services including PCP, specialists for both routine and acute visits. - Assess SDOH and provide psychosocial evaluations at member visits. - Support efforts to decrease hospital readmissions and high emergency department use. - Supports patients with Post Discharge follow up (Post Discharge Assessment) as needed and when requested by Care Partner. - Coordinate and contact with other care management resources the patient may be connected. - Support patients in re-aligning to ACO, MassHealth application and benefits. - Participate in weekly Interprofessional Care Team meetings. - Assist members in obtaining or stabilizing housing, finances, food, heating, educational/vocational opportunities (eg. DTA, housing applications, furniture applications ,fuel assistance, safelink phone, court visits, SSI applications) - Ensures appropriate documentation of visits and activities within EPIC system. - Addresses issues regarding substance misuse/ abuse, if indicated. - Uses recovery strategies such as motivational interviewing, harm reduction, positive behavioral support techniques, limit setting and strength based approaches to support patients in attaining goals. - Provides support and notifies Care Partner regarding changes in: behavior, nutrition, exercise, substance use, medication compliance, and other issues. - Provides 1:1 education to members regarding chronic disease self-management to prevent and manage health conditions and that encourages healthy behaviors and supports members in developing healthier habits. - Provides consultation and support to other members of the iCMP Plus Care Team.
  • Minimum Education Required – Associates Degree - Preferred Education– Bachelor’s Degree
3-5 years minimum experience in community-based care

4+ years of minimum experience working in outreach or in the community with members who have high behavioral health needs and high medical complexity. - CHW Certified - Required: - Excellent written and verbal communication skills. - Working knowledge of Microsoft Office applications - Excellent organizational skills. - Ability to utilize an Electronic Medical Record - Ability to use on-line training platforms - Demonstrated understanding of Mass health benefits - Ability to review welcome packets and obtain consent forms - Demonstrated understanding of LTSS - English required, bilingual preferred - The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job - Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions - While performing the duties of this job, the employee is regularly required to stand; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear - Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled
Salary Range
$29,000.00 - 47,000.00
per Year
Salary range estimated by
Boston, MA 02298, US
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