Community Health Worker, Complex Care (Personal Services)

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Time Type:

Full time

Department:

Quality

All Locations:

79 Paris Street

Position Summary:

NeighborHealth is a member of EB Wellsense Alliance, 501(c)(3) not-for-profit, Accountable Care Organization (ACO) governed by FQHCs. Our mission is to leverage the collective strengths of Federally Qualified Health
Centers (FQHC) to improve the health and wellness of the people we serve.

As an integral member of the care management team 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 members 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.

• Conduct initial outreach calls to encourage enrollees and care givers to participate in care management program
• 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 setting
• Share community assessment results with colleagues and community partners to inform planning and health improvement efforts
• Act as a cultural mediator by educating and supporting providers in working with clients from diverse cultures and help clients 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 member/representative to meet both personal and clinical goals
• 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 member/representative access community and government-based service agencies including completing 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
• Travel throughout assigned area and engage members at their homes/ hospitals/community-based locations and or accompany members to appointments as appropriate. As needed, cover other areas in person or via telephonic support
• 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.
• Be fully accountable for the completion of work within established timeframes and for achieving the goals established for the enrollee/family.
• Ensure that all services are offered in a culturally and linguistically appropriate manner, and with disability competence.
• Ensure that all needed accommodations are consistently made for members with disabilities.
• Use ACO care management tools and technology to ensure that work is comprehensive, detailed, automated and

streamlined to the extent possible. Make recommendations to change workflows to enhance the ease of use, practicality and effectiveness of the ACO tools and processes

• Understand the relationship between work done in the ACO's system and the work done in the FQHC's EHR. Ensure that workflows are optimized to recognize and support both the ACO's system and the FQHC's EHR.
• Use information about data trends for self-directed learning and performance improvement.
• Maintain excellent punctuality and attendance.
• Promote a sense of “team work” through demonstration of self-direction and self-motivation. Solve problems independently or knows when to seek consultation.
• Adheres to all NeighborHealth and departmental polices and procedures.
• Participate in required departmental activities and meetings
• Perform other related duties.

Starting hourly rate: $21.95 up to $32.93 based on experience.