Provides intensive case management and housing support services to individuals with health needs based criteria and risk factors. Coordinates intake, assessments, and treatment plans while facilitating access to community resources and essential healthcare.
Overview The Community Health Worker provides intensive case management services to individuals who have a Health Needs Based criteria (HNBC) and risk-factor as defined by Mass Health.
The Community Health Worker will support the Community Support Program (CSP) and Health Related Social Needs (HRSN) Supplemental Housing Services provided through MassHealth.
These services are designed to be maximally flexible in supporting individuals to implement their clinical treatment plans and attain the skills and resources needed to maintain community tenure.
The Community Health Worker also: Coordinates the completion of the Intake, Assessment, and Treatment Plan.
Conducts initial and ongoing risk assessment, designs personal crisis management plans, relapse prevention and harm reduction strategies with team clinician.
Drives referrals to any community or social services that align with a member's needs and goals.
Collaborates closely with PCP and other providers, including but not limited to community resources, to assure appropriate referrals based on the level of care needed which optimizes outcomes and minimizes risk.
Assists members in improving daily living skills so members are able to perform them independently or access services to support them in doing so.
Provides temporary assistance with transportation to essential medical and behavioral health appointments while transitioning to community-based transportation resources (e.g., public transportation resources, PT-1, etc.).
Accompanies members to essential health care appointments, as needed.
Assists with obtaining benefits, housing, and health care.
Collaborates with Emergency Services Programs/Mobile Crisis Intervention (ESP/MCIs) and/or outpatient providers; including working with ESP/MCIs to develop, revise and/or utilize crisis prevention plans and/or safety plans.
Performs other related duties, as assigned.
Keywords: VinfenOW
Responsibilities
The essential job duties/responsibilities of the position include but are not limited to the information listed below:
Coordinates the completion of the Intake, Assessment, and Treatment Plan.
Conducts initial and ongoing risk assessment, designs personal crisis management plans, relapse prevention and harm reduction strategies with team clinician.
Drives referrals to any community or social services that align with a member’s needs and goals.
Collaborates closely with PCP and other providers, including but not limited to community resources, to assure appropriate referrals based on level of care needed which optimize outcomes and minimize risk.
Assists members in improving daily living skills so members are able to perform them independently or access services to support them in doing so.
Provides temporary assistance with transportation to essential medical and behavioral health appointments while transitioning to community-based transportation resources (e.g., public transportation resources, PT-1, etc.).
Accompanies members to essential health care appointments, as needed.
Assists with obtaining benefits, housing, and health care.
Collaborates with Emergency Services Programs/Mobile Crisis Intervention (ESP/MCIs) and/or outpatient providers; including working with ESP/MCIs to develop, revise and/or utilize crisis prevention plans and/or safety plans.
Fosters empowerment, recovery, and wellness, including forming connections to recovery- oriented peer support and/or self-help support and services.
Manages all care transitions through collaboration with members, community provider staff, ICT, and hospital staff to ensure a safe discharge plan and a well-coordinated implementation of that plan.
Completes required Service Notes and case documentation in electronic health record to ensure accurate and timely billing of services.
Participates in routine multidisciplinary team meetings.
Completes all assigned courses on Vinfen Learning Management System and other training/in- service/workshops in best practices as assigned by supervisor.
Provides Pre-Tenancy Supports, including helping members identify housing preferences, assistance with budgeting or referral to housing financial aid programs, ensuring completion of subsidized housing applications, support with required follow up to applications and connection to community resources to access safe temporary housing.
Provides Tenancy Transition Services to individuals moving to new home environments to include lease negotiations, necessary accommodations, budgeting and rental payment plans, access to needed furniture, equipment and in home health services.
Qualifications
Typical Requirements:
Experience with and knowledge of affordable housing services and resources.
Experience working with people living with Serious Mental Illness (SMI) and/or Substance Use Disorder (SUD).
Bi-lingual/bi-cultural applicants and those with lived experience of BH conditions strongly encouraged to apply. Must have access to an operational and insured vehicle and be willing to use it to transport members. Preferred /Required Education:A Bachelor's or Master's degree in Mental Health, Social Services, or Criminal Justice preferred. In some cases, experience may be considered a substitute for academic training. Driving Requirements:Driving is a requirement for this position using either a Vinfen van or personal vehicle. - If using a personal vehicle, you must possess and maintain adequate insurance as well as maintain a safe driving record which is subject to annual checks. A valid driver's license must be presented at the time of employment. Incumbents must be at least 21 years of age, have maintained a valid US driver's license for at least one year, and must be able to pass a driver's screening background check. Physical Effort:Direct Care Roles - Ability to stand, walk, bend, kneel, stoop, crouch, crawl, climb as this is a very physically active position. Must be able to lift at least 25 pounds using proper lifting techniques or the use of a two-person lift. Ability to operate a computer and other office equipment such as a calculator, copier, and printer. Ability to sit, reach, climb stairs, and maneuver through narrow spaces or hallways. Ability to assist clients with tasks of daily living. Ability to speak, hear, and communicate with clients, staff, and external representatives. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus. For positions in day programs or group residences, the ability to assist in routine living activities including cleaning, meal preparation, vacuuming, shoveling, and grocery shopping. Required Certifications/Trainings:CPR within 2 weeks of hireFirst Aid within 2 weeks of hire Pay Range USD $51,000.00 - USD $51,000.00 /Yr.
Requirements
Requires experience with affordable housing services and working with populations living with Serious Mental Illness or Substance Use Disorder. A Bachelor's or Master's degree in Mental Health, Social Services, or Criminal Justice is preferred, and a valid driver's license is mandatory.
bachelor degree
postgraduate degree
Case Management
Patient Advocacy
Electronic Health Records
Risk Assessment
Trauma-Informed Care
Harm Reduction
Motivational Interviewing
Interdisciplinary Collaboration
Culturally Competent Care
Crisis Management
Person-Centered Planning
Housing First
Posting details
Employment type
Full Time
Work arrangement
On Site
Experience
2-5 yrs
Salary
$51,000 - $51,000/yr
Location
Lowell, Massachusetts
Posted
Jul 6, 2026
Closes
Jul 6, 2027
Application
Employer website
Provides Tenancy Sustaining supports to individuals with at risk tenancies include negotiating with landlords regarding accommodations, connecting to tenancy sustaining benefit programs, providing education regarding lease compliance, and connecting to legal, financial and other resources required for successful community living.
Performs outreach to assigned members to complete housing assessments and design targeted housing plans.
Completes in home assessment to determine remediation needs as needed and arranges for reputable contractor to address identified remediation need(s).
Identifies the need for and coordinates Home Modifications that ensure the member’s health, welfare, and safety, or enables the member to function independently in a community-based setting, in coordination with the NE Director of Care Coordination.
Uses evidence-based and promising practices that optimize care integration and effective communication acrosssystems of care, and that align with rehabilitation, recovery, and wellness principles, such as the Housing First approach to care.
Develops and maintains relationships with internal and external parties and agencies providing service to persons experiencing homelessness or who have at risk tenancies.
Uses recovery-oriented, person-centered, culturally competent, and strengths-based approaches to help members find, get, and keep housing.
Ensures all members are consistently provided with trauma informed and culturally responsive services.
Performs other related duties, as assigned. Knowledge and Skills:
Ability to collaborate as a member of multidisciplinary and cross-functional teams
Ability to function as an effective change agent
Ability to be flexible, open, and responsive to ongoing industry changes
Ability to articulate and communicate the CSP/HRSN Program mission
Ability to effectively represent the organization in a variety of circumstances and forums
Ability to identify opportunities and obstacles and develop effective, creative solutions
Knowledge of resources and systems impacting affordable housing and services required to support individuals with SMI/SUD to maintain tenancy
Knowledge of person-centered, strengths-based principles and modalities
Knowledge of clinical and psychiatric rehabilitation values, principles, and techniques
Knowledge of prevalent health risks for adults with SMI/SUD
Appreciation of the impact that Social Determinants of Health and stigma have on the lives of persons served including health access, experience, and outcomes
Knowledge of motivational interviewing, stage of change, and harm reduction techniques
Knowledge of trauma-informed and culturally responsive services
Sensitivity to cultural, religious, ethnic, disability, and gender issues
Ability to balance competing priorities
Ability to make independent judgments and decisions
Ability to work in a professional and confidential capacity
Knowledge of personal computer applications and equipment
Knowledge of types of available housing and housing subsidy programs and how to explore and identify housing opportunities in an unfamiliar community
Knowledge of housing first principles and requirements
Knowledge of formal and informal housing assessment skills and practices
Knowledge of the effects of prejudice (including internalized negative attitudes about oneself), discrimination, and oppression of people with psychiatric disorders and/or SUD, and the effects of poverty
Knowledge and use of different communication and learning styles
Ability to make independent judgments and decisions About Vinfen Established in 1977, Vinfen is a nonprofit, health and human services organization and a leading provider of community-based services to individuals with mental health conditions, intellectual and developmental disabilities, brain injuries, and behavioral health challenges. Our services and advocacy promote the recovery, resiliency, habilitation, and self-determination of the people we serve. Vinfen's 3,500 dedicated employees are experienced, highly-trained professionals who provide a full range of supportive living, health, educational, and clinical services in over 550 sites throughout Massachusetts and Connecticut. For more information about Vinfen, please visit www.vinfen.org/careers. My Job. My Community. My Vinfen. Vinfen is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, pregnancy, sexual orientation, gender identity, national origin, age, protected veteran status, or disability status.
Market context
Community health roles stay active in Massachusetts
Community Health Worker roles in Massachusetts are often tied to care coordination, outreach, and support for patients navigating social and health services, so demand tends to follow organizations focused on community-based care. These positions can be competitive because employers look for strong communication, comfort with Microsoft Office and Electronic Medical Records, plus BLS certification and a plan to complete CHW core competency training within two years. Before applying, review the summarized requirements and benefits here—pulled from the original job description to save research time—and be ready to show examples of patient support, documentation, and teamwork.
