Community Health Worker - Massachusetts; Franklin, Hampshire, Northern Berkshire, and Surroundi

Commonwealth Care Alliance® (CCA) is a nonprofit, mission-driven health plan and care delivery organization designed for individuals with the most significant needs. As an affiliate of Care Source, a nationally recognized nonprofit managed care organization with over 2 million members across multiple states, CCA serves individuals enrolled in Medicaid and Medicare in Massachusetts through the Senior Care Options and One Care programs and its care delivery enterprises.

CCA is dedicated to delivering comprehensive, integrated, and person-centered care, powered by its unique model of uncommon care®, which yields improved quality outcomes and lower costs of care.

The Community Health Worker - Massachusetts functions as a resource to enrollees on clinical care, health systems, and social drivers of health, supporting a panel of enrollees to overcome barriers to care and engagement related to social needs. This role utilizes evidence-based practices, key knowledge of community-based resources, recovery-informed principles, and coaching skills to improve member outcomes by impacting care access and utilization, closing care quality gaps, and optimizing member connection to medical, behavioral health, and substance use disorder resources.

• Review SDOH assessments and follow up based on enrollees' needs, goals, and preferences by participating in care planning and goal‑setting, providing appropriate resources, education and support in determining the most appropriate post‑intervention disposition.
• Conduct in‑person, virtual (telehealth), or telephonic visits with enrollees as needed or as requested.
• Support the creation of comprehensive and holistic plans of care and contribute to enrollee Care Plan goals pertaining to SDOH and social needs.
• Ensure appropriate, comprehensive, and timely documentation of all contacts, outreaches, assessments, and interventions in the Centralized Enrollee Record (CER).
• Identify gaps in care pertaining to SDOH that create barriers and result in unmet needs, identify areas of opportunity and defined resources, and collaborate with the Interdisciplinary Care Team to implement appropriate and timely interventions.
• Provide health education in collaboration with an enrollee’s Interdisciplinary Care Team and Primary Care Provider (PCP) or specialty care providers (e.g., behavioral health clinician).
• Participate in and contribute to team meetings as appropriate, provide consultation and expertise to colleagues, including other CHWs and members of the Interdisciplinary Care Team.
• May participate in the onboarding of newly hired CHWs via shadow visits and “onboarding buddies.”
• Support CHS Department programs and initiatives, including community engagement and development/education, and quality improvement initiatives.
• Participate in committees and work groups, as assigned.
• Perform any other job related duties as requested.

• High School or GED diploma required
• Associates degree preferred
• Two (2) years of experience in community or outreach settings working with clients who have complex needs, including medical, social, behavioral health, or substance use required
• Four (4) years of experience in health plan or managed care settings preferred

• Ability to communicate effectively and document work professionally and in a timely manner; ability to utilize SBAR communication
• Ability to provide compassionate and empathic care to enrollees with complex needs
• Ability to work in a dynamic and innovative healthcare environment; ability to manage change and multiple priorities
• Demonstrated understanding of SDOH and HRSN and the role they play in enrollee care; demonstrated expertise on local resources and benefits and how to access them
• Demonstrated experience with, or ability to learn, technological support tools including virtual/telehealth platform and video conferencing
• Demonstrated proficiency with Microsoft Office products (Word, Excel, Outlook, Teams)
• Bilingual preferred (Spanish, Vietnamese, Haitian Creole, Cape Verdean Creole, Portuguese)

• Must have valid driver's license, vehicle and…