Lead Community Health Worker

Description

The Lead Community Health Worker (CHW) advances health equity by addressing Social Determinants of Health (SDoH) and supporting improved outcomes for Fenway Health’s diverse patient population. Working in close partnership with medical providers, care teams, and community organizations, this role helps drive whole-person, integrated care.

Under the direction of the Manager of Behavioral Health Integrated Services, the Lead CHW delivers direct patient support while also strengthening the CHW program. This includes mentoring and training team members, supporting program coverage, and supervising interns and students. As a leader on the team, the Lead CHW fosters engagement, builds capacity, and ensures high-quality, patient-centered support across all Fenway Health clinical locations.

• Support the Nurse Care Coordinators with care coordination requests.
• Provides coverage of care coordination duties as needed.
• Assists patients with completion of paperwork.
• Provide patients with updated and accurate information regarding care coordination services.
• Actively build good working relationships with clients and colleagues
• Assists patients with applications for enrollment in programs as needed.
• Document in EHR for each patient interaction
• Assists department with care coordination administrative tasks such as completing and faxing client paperwork.
• Assist with outgoing phone calls to community resources as needed.
• Assists with distributing program materials to clients via mail as needed.
• Convey the purposes and services of a program to the patient population and the impact that program or service would have.
• Help patients develop health management plans and goals.
• Follow-up with health management/care plans with both patients and providers
• Coach patients in effective management of their chronic health conditions and self-care
• Assist patient in understanding care plans and instructions.
• Document activities, service plans, and results in an effective manner while strictly adhering to the policies and procedures in place.
• Establish positive, supportive relationships with participants and provide feedback.
• Assist patients in accessing health related services, including but not limited to: obtaining a medical home, providing instruction on appropriate use of the medical home, overcoming barriers to obtaining needed medical care and social services
• Facilitate communication and coordinate services between providers.
• Motivate patients to be active, engaged participants in their health.
• Build and maintain positive working relationships with the clients, providers, nurse case managers, agency representatives, supervisors and office staff.
• Continuously expand knowledge and understanding of community resources, services and programs provided; human relations and the procedures used in dealing with the public as part of a service or program; volunteer resources and the practices associated with using volunteers, operations, functions, policies and procedures associated with the department or program area, procedures and resources available to handle new, unusual or different situations.

• Develops maintains resource listings appropriate for Fenway Health patients
• Participates in community councils, boards and groups as appropriate to further departmental objectives
• Works with Medicaid, Medicare, Welfare, Social Security, housing, educational, day care and other institutions to assist clients
• Consults with a variety of health center and community staff (Nutritionists, Home Health Aides, Nurses, Behavioral Health staff and Medical staff) about specific clients and general approaches to patient treatment