Behavioral Health Transition of Care Community Health Worker at Community Care Cooperative in Boston, Massachusetts

Job Description:

Title: BH TOC Community Health Worker
Reports to: Manager, Behavioral Health Transitions of Care Program
Classification: Individual Contributor
Location: Central/Metro Massachusetts area (Worcester, Middlesex and Suffolk counties)
Job description revision number and date: 7/23/24

Organization Summary:

Community Care Cooperative (C3) is a 501(c)(3) non-profit, Accountable Care Organization (ACO) governed by Federally Qualified Health Centers (FQHCs). Our mission is to leverage the collective strengths of FQHCs to improve the health and wellness of the people we serve. We are a fast-growing organization founded in 2016 with 9 health centers and now serving hundreds of thousands of beneficiaries who receive primary care at health centers and independent practices across Massachusetts. We are an innovative organization developing new partnerships and programs to improve the health of members and communities, and to strengthen our health center partners.

Job Summary:

The Community Health Worker (Transitions of Care Program) will be a member of a team of social workers, physicians, pharmacists, community health workers, and program coordinators, you will have the opportunity to make a profound impact on the lives of people living with complex and/ or chronic mental health conditions, many of whom also face multiple barriers to accessing care and adhering to a providers treatment plan. The CHW works as an extension of the clinical care team. You will connect with your patients in person, on the phone, in the hospital, and in the providers office. You must be prepared to work from home office, hospital, Health Center, providers office setting, within patients homes, or in the community.

Responsibilities:

Works under the guidance of the Behavioral Health TOC Social Work Care Manager
Conducts initial outreach calls to encourage patients and caregivers to participate in care management programs
Meet with members in person in the community and/or at the health centers
Engages with patients who need assistance with psychiatric and/or substance use recovery care needs
Addresses language and cultural barriers to care
Coaches and guides the patient to meet psychiatric and other clinical goals
Helps teach the patient and/or care giver about psychiatric and/or substance misuse symptoms response plans
Assists in scheduling appointments on behalf of patients and reminds patients of their upcoming visits
Accompanies patients to their visits as needed
Completes Social Determinants of Health Assessments
Helps patients access community and government-based service agencies including filling out paperwork for the patient
Arranges transportation as needed (PT1)
Establishes relationships with community agencies, resources, and supports that are relevant to the Medicaid population
Assists with Medicaid applications, food and nutrition benefits, housing applications, coordinating transportation, etc.
Travels to engage members at their homes or in the community
Participates in the integrated care team meetings and rounds as required
Maintains accurate, timely documentation in electronic systems
Provides team support as needed

Required Skills:

Demonstrated success in working as part of a multi-disciplinary team including communicating and working with providers, nurses, and social workers
Experience working with patients with chronic and mental health and/or substance misuse needs
Must be flexible and adaptable to change
Ability to work independently
Excellent interpersonal communication skills
Additional qualities that would be a good fit for our team include enthusiasm and passion for helping patients, genuine spirit, kind and empathetic nature
Experience working with Electronic Medical Records and healthcare systems
Experience and proficiency with Microsoft Office and online record keeping

Desired Other Skills:

Familiarity with the MassHealth ACO program
Familiarity with Federally Qualified Health Centers
Experience with anti-racism activities, and/or lived experience with racism is highly preferred
Bi-lingual (preferred)

Qualifications:

Experience working with Medicare, Medicaid and/or Special Needs populations
A valid driver's license and provision of a working vehicle

** In compliance with Covid-19 Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law. **