Community Health Worker II - Primary Care Complex Care Mgmt

Location
: 1035 Cambridge Street
Category
:
Human and Social Services
Department
:
Primary Care Complex Care Mgmt
Job Type
:
Full time
Union Name
:
Union of Social Workers

Work Schedule:

Day Length Of Shift(s) In

Hours:

8
Shift Details: M-F 8-4:30
Hours/Week: 40.00
Weekend Requirements: no
Holiday Requirements: no
On Call Requirements: no

The Complex Care Team is responsible and accountable for developing, coordinating, and facilitating care management plans and services for CHA patients who are most at risk for health deterioration, poor outcomes, and high cost/low value interventions. Our team of nurses, social workers and community health workers works in collaboration with our primary care and specialty practices to ensure that that care for the most vulnerable patients is coordinated and managed to deliver on the three goals of the Triple Aim - improved health outcomes, excellent patient experience of care and greater healthcare value.

The team works to insure that high risk patients receive optimal care including acute illness management, chronic disease management, intensive care coordination and preventive care across multiple health settings and multiple physicians/providers.

The (Hospital to Home) CHW II will work closely with the Complex Care Management team, primary care and inpatient teams, and community partners providing short-term support to patients transitioning from the hospital, skilled nursing facilities (SNFs), and other post-acute care settings back to the community. The CHW will assess patient’s ability to follow discharge plan, including meds;
Identify and address barriers to discharge plan, conduct a health-related social needs assessment, Insure patient has and attends CHA follow-up appointment and Identify patients with higher risk needs and refer to the Complex Care Management (CCM). All responsibilities of the CHW will be consistent with the scopes of practice acts governing community health workers in Massachusetts.

• Conducts outreach and engagement work with assigned patients.
• Conducts HRSN screening, navigation to resources, Transitions of Care support to assigned patients.
• Conducts navigation and care coordination with patient, CHA primary care, CHA inpatient and other community based teams and services.
• Transition patient to CHA or community-based care management programs when appropriate
• Other duties as assigned by supervisor

• College degree in health science, social science or health preferred or 3 yrs of relevant community work experience in program topic area
• Licensure:
  Community Health Worker Certification or Certification eligible
• Requires ability to travel between multiple sites such as primary care sites, hospitals/ specialty care, or community locations.
• Work Experience:
  
  Minimum of two years experience in community health worker role required.
• Experience with multi-cultural and multi-lingual populations required.
• Shared lived experience similar to population/program topic served preferred
• Bilingual (English and Portuguese, Haitian Creole or Spanish) strongly preferred

Please note that the final offer may vary within the listed Pay Range, based on a candidate's experience, skills, qualifications, and internal equity considerations.

In keeping with federal, state and local laws, Cambridge Health Alliance (CHA) policy forbids employees and associates to discriminate against anyone based on race, religion, color, gender, age, marital status, national origin, sexual orientation, gender identity, veteran status, disability or any other characteristic protected by law. We are committed to establishing and maintaining a workplace free of discrimination. We are fully committed to equal employment opportunity.

We will not…