Why This Role is Important to Us:

The Community Health Worker (CHW) is responsible for supporting social determinants of health (SDOH) needs for a panel of individuals in the context of a member-led plan of care. The CHW will utilize evidence-based resources, knowledge of community-based care and supports, trauma/recovery skills, and health coaching/education to connect members with community supports. The CHW will help the member to access the best types of care for their needs including community long-term services and supports. They will focus on reducing gaps in preventive care interventions, optimize members' engagement with primary care, behavioral health, and substance use services. The CHW will play an integral role supporting members with frequent utilization of Emergency Departments and acute admissions with the goal of identifying SDOH factors that may be contributing, and partnering with the member to identify more efficacious and appropriate supports that empower the member and meet his/her needs. Massachusetts Community Health Worker reports to the CHW Manager.

Supervision Exercised: None

What You'll Be Doing:

As an integral part of an Interprofessional Care Team and based on the fluctuating needs of a defined panel of members, the Community Health Worker will engage in regular assessments pertaining to Social Determinants of Health, visit and/or outreach members telephonically at regularly scheduled intervals, and conduct urgent follow-ups to ensure that members' Plan of Care is fully comprehensive and addresses significant medical, behavioral, and social needs. The CHW works toward the promotion, prevention, and reduction of health risks. The CHW will support the health education needs of the member in collaboration with the Interprofessional Care Team and PCP.

The Community Health Worker will assess health risks and identify gaps pertaining to SDOH which create barriers to member's care and contribute to unmet needs. The Community Health Worker will coordinate with the Care Partner and the member's PCP (Primary Care Provider), as well as CCA's interprofessional clinical care team to identify areas of opportunity, as well as defined resources, and will work in coordination with the team to implement the care plan. In collaboration with the member, the CHW will take ownership of SDOH goals in the member's care plan and will provide input and support for key care management or coordination decisions.The CCA CHW:

Facilitates and/or delivers preventative care and health coaching to members according to guidelines set by CCA Clinical Leadership

Identifies and initiates a member agreed-upon plan to resolve areas of opportunity to meet quality metrics

Assesses members' social determinants of health (SDOH), and provides support, further evaluation, or coaching as needed to support members in prioritizing their needs and goals

Supports efforts to decrease hospital readmissions and high emergency department use

Supports member retention and connection to Medicaid benefits

Provides Diabetes Basics or other health coaching/education to members, as appropriate to support members' goals and care plan

Supports health education to members on key quality metrics, including preventive care/screenings

Participates in weekly Interprofessional Care Team meetings, as well as ad hoc case conferences when needed

Participates in Root Cause Analysis (RCA) as needed

Assists members in obtaining or stabilizing housing, finances, food, utilities, educational/vocational opportunities, and community supports

Liaises with CCA Care Partner and community-based PCPs/ Specialists as needed.

Engages with community agencies and service providers to build relationships to support membership

Ensures accurate and complete documentation of visits and activities within CCA's central medical record and within the record of partners as indicated

Addresses issues regarding substance misuse/abuse, if indicated, in conjunction with Behavioral Health Clinicians and supports

Uses recovery strategies such as motivational interviewing, harm reduction, positive behavioral support techniques, limit setting, and strengths-based approaches to support members in attaining stated goals

Provides support and notifies Care Partner regarding changes in behavior, nutrition, exercise, substance use, medication compliance, housing/resource stability, and other issues as related to the established care plan

Provides 1:1 health education to members regarding chronic disease self-management to prevent and manage health conditions and encourage development of healthy behaviors/habits

Provides consultation and support to other members of CCA Care Team

Maintains appropriate written and oral communication on a timely basis, completing documentation within 24 hours of activity, and returning non-urgent calls within 48 hours

Actively participates in the evaluation of own performance and progress

Participates in ongoing education and training to improve skills and role-specific certifications or specialization

Participates in CCA quality improvement efforts

Assists CCA management and leadership with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects

Participates in committees and workgroups that promote clinical excellence and help to advance CCA's mission and business objectives

Provides clinical care to members via telehealth technologies (i.e., video, chat) for clinically appropriate clinical care and care management services

Other duties as assigned

Working Conditions:

Must be willing and able to travel to members' homes

Must be willing and able to travel to the CCA office for required meetings

Must be willing and able to travel to other CCA sites across the state assigned to work, and may require travel across state lines

Valid driver's license with no restrictions in the state assigned to work

What We're Looking For:

Qualifications:

Associates Degree orEquivalent Experience required, Bachelor's Degree,Master's Degree preferred

CHW certification

3+ years working in outreach or community-based care with members who have high behavioral health needs and high medical complexity required

Experience with electronic medical record strongly preferred (eCW a plus)

Knowledge, Skills Abilities Required:

Strong written and oral communication skills and the ability to accurately document interactions in a clinical record

Strong technology skills in Microsoft products

Ability to utilize an Electronic Medical Record (EMR) and other electronic platforms

Ability to use on-line training platforms

Ability to review welcome packets and obtain consent forms and attach them to EMR

Willing to learn and utilize telehealth technologies (i.e., video, chat), when appropriate, for a variety of clinical care and care management services

Language(s) Required:

EnglishLanguage(s) Desired:

Bilingual Spanish/Vietnamese preferredOther Required:

Standard office equipment

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

The employee is occasionally required to walk; sit; and stoop, kneel, crouch, or crawl

The employee must frequently lift and/or move up to 10 pounds

Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.