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Community Health Worker-South East(Brockton)/Cape Cod Region

  • Full Time
  • Anywhere

Community Care Cooperative

Title:  Community Health Worker

Reports to:  Senior Manager, Transitions of Care Program

Classification: Individual Contributor

Job description revision number and date: 1.0 1/21/19


Community Care Cooperative (C3) is a new, 501(c)(3) not-for-profit, Accountable Care Organization (ACO) governed by FQHCs. Our mission is to leverage the collective strengths of Federally Qualified Health Centers (FQHC) to improve the health and wellness of the people we serve.

The Community Health Worker (Transition of Care Program) will be a member of a team of nurses, social workers, registered dieticians, physicians, pharmacists, community health workers, and program coordinators, you will have the opportunity to make a profound impact on the lives of people living with complex and/ or chronic conditions, many of whom also face multiple barriers to accessing care and adhering to a provider’s treatment plan. The CHW works as an extension of the clinical care team. You will connect with your patients in person, on the phone, in the hospital, and in the providers office.  You must be prepared to work from home office, hospital, Health Center, provider’s office setting or within patient’s homes.


  • Works under the guidance of the Care Advisor
  • Conducts initial outreach calls to encourage patients and caregivers to participate in care management programs
  • Engages with patients who need assistance with self-care needs beyond what a care advisor can provide via phone
  • Addresses language and cultural barriers to care
  • Coaches and guides the patient to meet both personal and clinical goals
  • Assists in scheduling appointments on behalf of patients
  • Accompanies patients to their visits as needed
  • Reminds patients of their upcoming visits
  • Helps patients access community and government-based service agencies including filling out paperwork for the patient
  • Helps teach the patient and/or care giver about symptom response plans
  • Arranges transportation as needed (PT1)
  • Participates in the integrated care team meetings and rounds as required
  • Completes Social Determinants of Health Assessments
  • Maintains accurate, timely documentation in electronic systems
  • 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 a Medicaid Population.
  • Assist with Medicaid applications, food and nutrition benefits, housing applications, coordinating transportation, etc.
  • Travel throughout assigned area and engage members at their homes
  • As needed, cover other areas in person or by phone

Desired Skills:

  • Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Providers, Nurses, and Social Workers
  • Bi-lingual (preferred)
  • Experience working with patients with chronic and behavioral health needs
  • Must be flexible and adaptable to change. Demonstrate the ability to work independently
  • Must demonstrate excellent interpersonal communication skills
  • Additional qualities that would be a good fit for our team include: Enthusiasm and passion for helping patients, genuine spirit, kind and empathetic nature, and one who embraces a ‘go with the flow’ mentality
  • Experience working with Electronic Medical Records and health care systems
  • Experience and proficiency with Microsoft Office and online record keeping


  • Medical Assistant, Engagement Specialist or Community Health Worker Certification
  • Experience working with Medicare, Medicaid and/or Special Needs populations
  • A valid driver’s license and provision of a working vehicle

To apply for this job email your details to hr@c3aco.org