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Community Health Worker, Springfield Health Services for the Homeless Health Center (SHSH)

Community Care Cooperative

Summary:

Community Care Cooperative (C3) is a new, 501(c)(3) not-for-profit Accountable Care Organization (ACO) made up of 17 Federally Qualified Health Centers (FQHCs).  As of January 2019, C3 membership is estimated to be approximately 123,000 MassHealth beneficiaries.

The Community Health Worker, a member of the broader multi-disciplinary care team at Springfield Health Services for the Homeless Health Center (SHSH), will have the opportunity to make a profound impact on the lives of ACO patients experiencing homelessness or housing instability in addition to medical, behavioral and/or substance use disorder issues. The Community Health Worker will serve as a critical link for patients, the health center multi-disciplinary teams and community-based and hospital-based services.

Responsibilities:

Specific responsibilities include:

·       Serve as the liaison between the health center (primary care teams, case managers, integrated behavioral health, etc.) and external community-based organizations, hospitals, ER departments, and other facilities

·       Coordinate with Behavioral Health (BH) and Long-Term Services & Supports (LTSS) Community Partners (CPs) to ensure seamless handoffs, appropriate exchange of information, and to facilitate the review and approval of the patient’s comprehensive assessment and care plan

·       Coordinate with the Transitions of Care (TOC) team to ensure seamless handoffs, appropriate exchange of information and effective co-management of patients with a medical or behavioral health hospital admission or emergency department visit

·       Coordinate with homeless shelters, behavioral health institutions and others as needed

·       Participate in the integrated care team meetings and huddles

·       Work directly with patients in clinic on Health-related Social Needs and Care Coordination services

·       Assist patients in accessing community and government-based service agencies including possibly filling out paper work for patients

·       Conduct telephonic outreach to the “yet-to-be-reached” and “lost-to-contact” patients

·       Utilize a variety of outreach strategies to engage the health center ACO population

·       Educate and inform patients on services/programs offered

·       Arrange transportation for patients

·       Work closely with the clinical team to support patient engagement and confirm the patient has connected with resources, as appropriate

·       Contact provider offices and other clinical settings to obtain clinical data and/or patient demographics to facilitate care

·       Other duties as required

Qualifications (required):

·       Prior experience working in primary care, preferably community-based health center experience

·       Prior care coordination and/or administrative experience in the health care field

·       Good computer skills including proficiency with Microsoft (Office, Excel, Word)

·       Excellent relationship-building, communication and engagement skills

·       Ability to work independently and solve problems

·       Strong organizational skills and attention to detail

·       High level of professional and interpersonal skills

·       Ability to positively influence others with respect and compassion

·       Willing and interested in learning new skills

·       Flexible and comfortable with ambiguity and change

·       Bilingual skills in English and Spanish

·       Reliable transportation and ability to travel between locations

Preferred (not required)

·       Knowledge and experience with eClinicalWorks electronic health record

·       Experience working with patients with chronic and behavioral health needs

·       Demonstrated success in working as part of a multi-disciplinary team including communicating and working with providers, registered nurse, MAs, and behavioral health teams

·       Healthcare-related certificate degree, Massachusetts CHW certificate, or bachelor’s degree/ Medical assistant, home health aide, nursing assistant or other similar health care training

·       Experience working directly with patients, physicians, physician office staff, healthcare team, etc. telephonically (i.e. call center)

·       Experience with Medicaid / MassHealth

We offer a competitive salary, health, dental and vision insurance, disability coverage and unlimited vacation time.

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