Community Health Worker

Community Health Connections (CHC) is a multi‑site, non‑profit health care center offering urgent care, primary family medical and pediatric care, preventative and restorative dental care, oral surgery, behavioral health services for children and adults, substance use disorder treatment, and specialty services including optometry, acupuncture, nutrition consultations, and podiatry. CHC is mission‑driven, providing compassionate, quality health care regardless of income or health insurance status.

With five sites in Fitchburg, Gardner and Leominster and a Federally Qualified Health Center (FQHC) designation, CHC serves 36 communities in North Central Massachusetts.

As a Care Coordination Specialist (CCS), you will be an essential member of a multidisciplinary team of nurses, care coordinators, providers, nutritionists, social workers, and other care‑management staff. You will connect with vulnerable, underserved individuals and families to promote access to community services, provide health education, support care delivery, and advocate for patients. Your work ensures patients can access culturally and linguistically appropriate services in a timely and cost‑effective manner through outreach in community, home, facility, or health‑center settings.

• Conduct assessments of patients’ medical, behavioral and social needs to identify gaps in care.
• Act as a liaison between providers, social service organizations, schools, shelters, hospitals and community resources to facilitate access to services.
• Provide basic screening, education and brief intervention; facilitate referrals to health‑center or community resources for chronic diseases, depression, healthy weight management, and substance use including tobacco use.
• Offer guidance and support related to transportation, utilities, housing, food security, domestic violence, legal aid, employment, child‑care benefits, insurance and other financial matters.
• Educate patients and families about needed services, assist through diagnostic and treatment processes, and coordinate with RN or Behavioral Health Care Coordinator.
• Assist patients in scheduling appointments with PCP, specialists or community agencies.
• Serve as a contact point, advocate and resource for patients, families and providers, building effective relationships based on trust, respect and communication.
• Maintain timely verbal and written communication with providers, care coordinators, patients and families.
• Identify and address barriers to receiving recommended health services, adherence to treatment plans and effective self‑management.
• Monitor and communicate patients’ progress toward care‑plan goals and appointment adherence.
• Follow up with provider‑identified patients to assess and address psycho‑social barriers limiting engagement.
• Participate in community outreach, patient recruitment and service connection activities.
• Track, follow up and report diagnostic and specialist referrals; close the loop on all test and consult results.
• Assist with transitions of care, including outreach after ER and hospital admissions.
• Work independently on special non‑recurring and ongoing projects as needed.
• Participate in departmental, team and organizational meetings and QI projects.
• Engage in continuing education programs and trainings to meet certification or regulatory requirements.

• High school diploma or equivalent required; associate’s degree or higher preferred.
• Demonstrated written and verbal communication skills in English. Bilingual Spanish is a plus.
• Valid U.S. motor vehicle license and reliable transportation for outreach activities.
• Minimum 1 year of work or volunteer experience in human services or healthcare with knowledge of targeted community needs. Medical assistant certification is a plus.
• Ability to engage and positively influence others.
• Knowledge of community and healthcare system resources.
• Computer proficiency in Microsoft Office.
• Experience working with an electronic health record preferred.

• 401(k)
• Generous vacation and personal time for eligible employees
• Sick time
• Medical, dental and vision insurance
• 100% paid life insurance/AD&D
• 100% paid long‑term disability
• Discounts on travel, entertainment, cell phone service, computers and more
• College tuition rewards/CMEs
• Company events and activities (annual cookout, holiday party, health and wellness events, lunch & learn, team building)
• Employee assistance program (EAP)
• Eye Med vision care program
• Accident and cancer insurance
• Educational development reimbursement
• Discounts on gym membership, travel and entertainment tickets, electronics and more

• Entry level

• Full‑time

• Health Care Provider

• Hospitals and Health Care