ACO Community Health Work

Job Description

Job Description

Job Summary:

As an integral member of the care management team, the Community Health Worker (CHW) will have the opportunity to make a profound impact on the lives of individuals living with complex and/ or chronic conditions, many of whom also face multiple barriers accessing care and need support to succeed with achieving health care goals. This position requires flexibility and may vary from day to day to meet members where they are. Outreach methods may vary based on the needs of the organization and may include telephonic or in-person support in a variety of potential settings, such as but not limited to, the community, home, facility, or health center.

Principal Responsibilities and Duties:

● Works under the guidance of the Licensed Care Manager and Director of Nursing.

● Conducts initial outreach calls to encourage members and caregivers to participate in care

management programs and reduce health care disparities.

● Identify and share appropriate information, referrals, and other resources to help individuals,

families, groups, and the primary care team meet their needs.

● Gather and combine information from different sources to better understand members, their

families, and communities.

● Use a range of outreach methods (telephonic/in-person) to engage members in care.

● Coaches and guides members to meet both personal and clinical goals.

● Assists in scheduling appointments on behalf of the member.

● Work with individuals, family, community members, primary Care Managers (CM), and primary care team to address issues that may limit opportunities for healthy behavior. This includes completing Social Drivers of Health (SDOH) screening and other tactics to obtain support for barriers to care.

● Provide care coordination, which may include, but not be limited to, facilitating care transitions,

supporting the completion of referrals, and providing or confirming appropriate follow-up.

● Help bridge cultural, linguistic, knowledge, and literacy differences among individuals, families, communities, and providers and address language and cultural barriers to care.

● Helps members access community and government-based service agencies, including completing paperwork for the member.

● Helps teach the member and/or caregiver about symptom response plans.

● Participates in the integrated care team meetings and rounds as required.

● Creates and maintains a comprehensive inventory of local community resources, improving

accessibility for patients and providers, and linking patients with the appropriate support

services.

● Establishes relationships with community agencies, resources, and supports that are relevant to the Medicaid Population.

● Assist with Medicaid applications, food, and nutrition benefits, housing applications, coordinating transportation, etc.

● Travel throughout the assigned area and engage members at their homes/ hospitals/community -based locations and/or at the health center as needed.

● As needed, cover other areas in person or via telephonic support.

● Other duties as assigned.

Required Skills:

● Experience within the ACOs member population preferred, including Medicare/Medicaid

● Demonstrated success in working as part of a multi-disciplinary team, including communicating and working with Providers, Nurses, Social Workers, and other health care teams.

● Bi/multi-lingual preferred or experience with Language Translation Services

● Experience working with patients with chronic medical and behavioral health needs.

● Must be flexible and adaptable to change.

● Demonstrate the ability to work independently.

● Must demonstrate excellent interpersonal communication skills.

● Experience using appropriate technology, such as computers, for work-based communication, according to organizational requirements.

Other Desired Skills:

● Familiarity with the MassHealth ACO program

● Familiarity with Federally Qualified Health Centers

Qualifications:

● Minimum 2-5 years of experience as a Community Health Worker (CHW), Medical Assistant (MA), Engagement Specialist, Care Coordinator, or Care Advocate.

● A valid driver's license and provision of a working vehicle.

Working Conditions:

● This position involves prolonged use of a telephone and extended periods of computer-based work at a workstation

● It requires the ability to sit for long durations, with occasional standing and walking