Care Management-CHW (5274)

As an integral member of the care management team the Community Health Worker (CHW) will have the opportunity to make a profound impact on the lives of people living with complex and/ or chronic conditions, many of whom also face multiple barriers accessing care and need support to succeed with achieving health care goals. This position requires flexibility and may vary from day-to-day to meet patients where they are. Outreach methods may vary based on the needs of the organization and may include telephonic or in person in a variety of potential settings such as but not limited to, the community, home, facility, or health center. This position is grant funded by the MassHealth C3 Accountable Care Organization (ACO). The budget and requirements are based on the C3 Delegation Agreement with BNHC and are subject to change. PRINCIPAL DUTIES AND RESPONSIBILITIES: Works under the guidance of the Program Leaders (Supervisor or Manager). Conducts initial outreach calls to encourage patient/representative and caregivers to participate in 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, their families and communities. Initiate and sustain trusting relationships with individuals, families, social networks and primary 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 and health improvement efforts. Use effective communication skills Act as a cultural mediator by educating and supporting providers in working with patients from diverse cultures and help patients and community members interact effectively with professionals to promote health, improve services, and reduce health care disparities. Addresses language and cultural barriers to care. Coaches and guides patient/representative to meet both personal and clinical goals. Assists in scheduling appointments on behalf of patient/representative.

Work with individuals, family, community members, primary CM and primary care team to address issues that may limit opportunities for healthy behavior. This includes completing Social Determinants of 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 patient/representative access community and government-based service agencies including completing paperwork for the member. Helps teach the patient/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 and health center requirements. Creates and maintains a comprehensive inventory of local community resources, improving accessibility for patients and providers, and linking patients with the appropriate support services. Establishes relationships with community agencies, resources and supports that are relevant to a Medicaid Population. Assist with Medicaid applications, food, and nutrition benefits, housing applications, coordinating transportation, etc. Complete programmatic and other relevant trainings. Work 1 day remote per week (conditional upon performance). As needed, cover other areas in person or via telephonic support. Other duties as assigned. MassHealth C3 ACO Key Performance Indicators (KPIs): Based on 1.0 Full Time Employee CHW: Annual Enrollment is 185 patients per year. Enrolled Caseload is 40 patients. Average Case Duration is (45 days). (These requirements are based on the C3 Delegation Agreement with BNHC and are subject to increase.) SKILLS:

Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Providers, Nurses, Social Workers, and other health care teams.

Bi-lingual (preferred).

Experience working with patients with chronic and behavioral health needs.

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, genuine spirit, 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 keeping.

Knowledge and/or experience with health, social, and racial inequities and disparities. QualificationsQUALIFICATIONS:

Experience working in the social, behavioral, and medical health systems is preferred.

Experience working with the Pediatric and Young Adult population is preferred.

1 year case management experience with a bachelor’s degree in social work, Psychology or related field.

2 years case management experience with a Community Health Worker Certificate or associate’s degree in social work, Psychology, or related field. WORKING CONDITIONS: A busy community health center located in a downtown business district. Occasional long hours may be required. Walking commutes between site locations may be required. PHYSICAL REQUIREMENTS: Physical demands requiring lifting of small pieces of equipment and/or boxes not to exceed 20 pounds. Mostly sedentary, with interoffice walking required. Visual acuity sufficient for frequent reading. Hearing acuity sufficient for holding conversations with or without audio devices. At Brockton Neighborhood Health Center, we are dedicated to providing high quality health care that is delivered by Committed, Competent, Compassionate staff who respects the dignity, privacy, and equality of each patient and colleagues. Our team believes that Teamwork, Diversity, Respect, Customer service and Collaboration are essential for everyone to be successful in their role.