Community Health Worker

024800 Clin Alli-Community Health Services

Position Summary: Commonwealth Care Alliance’s Community Health Services (CHS) Department is responsible for addressing health related social needs (HRSN) and social determinants of health (SDOH) for enrollees in One Care (ICO) and Senior Care Options (SCO) plans. Community Health Workers (CHWs) are key supports to interdisciplinary care management teams and complement and support enrollees’ needs, goals, and preferences. The Community Health Worker is knowledgeable of clinical care, health systems, and social drivers of health, and ensures that a panel of enrollees overcomes barriers to care and engagement related to social needs. CHWs utilize evidence-based practices, key knowledge of community-based resources, recovery-informed principles, and coaching skills to improve CCA enrollee outcomes by impacting care access and utilization, closing care quality gaps, and optimizing member connection to medical, behavioral health, and substance use disorder resources. CHWs play an integral role in reducing high emergency department (ED) and inpatient utilization related to unmet social needs, including housing, food, community resources (e.g., utility support), transportation, and digital literacy. CHWs support CCA’s current and future Community Health Services programs and initiatives, including housing programming, community resource engagement, place-based supports, and/or the Doula Program.
The CHW reports to the Community Health Services Manager.

Supervision Exercised:
•    No, this position does not have direct reports.  

Essential Duties & Responsibilities:

• CHWs are subject matter experts on SDOH and HRSN. CHWs assess and educate enrollees in key areas including food, housing, transportation, benefit maintenance, community resources/programs, health/vocational training, and digital literacy. CHWs follow-up on SDOH assessment for enrollees and intervene by care planning and goal-setting, providing appropriate resources and support, and determining the most appropriate post-intervention disposition. CHWs provide intensive episodic support, average 3-6 months, to enrollees based on their needs, goals, and preferences. CHWs conduct in-person, virtual (telehealth), or telephonic visits with enrollees as needed or as requested.
• CHWs support creation of comprehensive and holistic plans of care and contribute to enrollee Care Plan goals pertaining to SDOH and social needs.
• CHWs ensure appropriate, comprehensive, and timely documentation of all contacts, outreaches, assessments, and interventions in the Centralized Enrollee Record (CER). CHWs communicate orally and via writing with professionalism.
• CHWs identify gaps in care pertaining to SDOH that create barriers and result in unmet needs. CHWs identify areas of opportunity, as well as defined resources, and collaborate with the Interdisciplinary Care Team to implement appropriate and timely interventions.
• CHWs work toward the promotion, prevention, and reduction of health risks, including providing health education in collaboration with an enrollee’s Interdisciplinary Care Team and Primary Care Provider (PCP) or specialty care providers (e.g., behavioral health clinician).
• CHWs utilize recovery-centered strategies, harm reduction skills, positive behavioral support techniques, strengths-based approaches, and appropriate boundaries to support enrollees in achieving their stated goals.
• CHWs participate in and contribute to team meetings as appropriate, scheduled departmental meetings, individual supervision with the CHS Manager, and other group meetings as scheduled. CHWs provide consultation and expertise to colleagues, including other CHWs and members of the Interdisciplinary Care Team.
• CHWs complete mandatory clinical, staff safety, and compliance education and training in a timely manner.
• CHWs foster mentoring, coaching, and training within the CHS Department. Under the guidance of the CHS Manager, CHWs may participate in the onboarding of newly hired CHWs via shadow visits and “onboarding buddies,” modeling workflows, role functions, and documentation practices; and promoting CHW core competencies as per the National Association of CHWs (NACHW).
• CHWs support CHS Department programs and initiatives, including community engagement and development, topical education and workshops (e.g., housing, digital literacy), place-based supports, grant-related activities, the Doula Program, equity, and quality improvement initiatives. CHWs participate in committees and work groups that promote clinical excellence and advance CCA’s mission, values, and business objectives.
• CHWs are mandated reporters and are expected to report suspected abuse or neglect via appropriate channels and reporting procedures, including CER documentation and required internal or State processes.
• CHWs perform other duties as assigned to support enrollee and business needs.

All CCA employees:

• Are expected to demonstrate integrity by working with passion, commitment, and honesty, acting in the best interests of colleagues and enrollees.
• Approach work in a collaborative and caring manner and interact with insight, sincerity, and compassion.
• Demonstrate accountability by delivering on commitments, owning mistakes as well as successes, and contributing to an empowering and innovative environment where the focus is on solving problems and learning from errors.
• Recognize, respect, and celebrate diversity in all forms.
• Strive for excellence in the fulfillment of CCA’s mission via quality, innovation, and continuous learning.
• Demonstrate initiative, flexibility, and openness to change.
• Represent CCA and its clinical affiliates with professionalism.
• Keep current and proficient with necessary skills and knowledge; self-identify training and development needs relevant to work and responsibilities.
• Adhere to all applicable compliance requirements, including but not limited to:

• Complete annual compliance training in a timely manner; promote and enforce the CCA compliance program
• Review the Code of Conduct at least annually and adhere to the content within
• Adhere to CCA policies and procedures
• Promptly, in good faith, report any instances of suspected fraud, waste, or abuse; suspected privacy and/or security incidents; or any other compliance concerns identified
• Ensure confidentiality of HIPAA-protected communications, as well as enrollee and company proprietary information

Working Conditions:

• Work locations include residential and community sites.

Required Education (must have):

• Associate’s Degree with 3+ years of relevant experience, OR
• High school diploma with 5+ years of relevant experience

Desired Education (nice to have):

• Bachelor’s Degree
• Graduate Level Degree (e.g., MSW, MA, MS)

Required Licensing (must have):

• Valid driver’s license with no restrictions and reliable access to transportation required.

Desired Licensing (nice to have):

• DPH CHW Certification strongly preferred
• Doula Certification (DONA)
• Certified Peer Specialist (CPS)
• Certified Alcohol and Drug Counselor (CADC)
• Housing Navigator/Specialist
• Health/Wellness Coach Certification

MA Health Enrollment (required if licensed in Massachusetts):

• No, this is not required for the job. 
   

Required Experience (must have):

• 3+ years in community or outreach settings working with clients who have complex needs, including medical, social, behavioral health, or substance use

Desired Experience (nice to have):

• 5+ years in health plan or managed care settings

Required Knowledge, Skills & Abilities (must have):

• Ability to communicate and document work professionally and in a timely manner; ability to utilize SBAR communication
• Ability to provide compassionate and empathic care to enrollees with complex needs
• Ability to work in a dynamic and innovative healthcare environment; ability to manage change and multiple priorities
• Demonstrated understanding of SDOH and HRSN and the role they play in enrollee care; demonstrated expertise on local resources and benefits and how to access them
• Demonstrated experience with, or ability to learn, technological support tools including virtual/telehealth platform and video conferencing
• Demonstrated proficiency with Microsoft Office products (Word, Excel, Outlook, Teams)
• While performing the duties of this job, the employee is required to sit, stand, use hands to finger/handle/feel, reach with hands or arms, talk, and hear. The employee is occasionally required to walk, stoop, crouch, kneel, or crawl. The employee must lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus. Reasonable accommodations may be made to enable individuals with disabilities to perform essential job functions.
• CHW is a mobile position. CHWs must be willing and able to travel to enrollees’ homes or community locations as required, in addition to working in an office environment. Must be willing and able to travel to CCA offices and to other CCA sites across Massachusetts as required. Valid driver’s license with no restrictions and reliable access to transportation required.

Required Language (must have):

• English required
• Bilingual preferred (Spanish, Vietnamese, Haitian Creole, Cape Verdean Creole, Portuguese)

Desired Knowledge, Skills, Abilities & Language (nice to have):

• Experience with medical or enrollee record systems, including Health Edge/Guiding Care
• Experience with telephony systems, including relays, messaging, and call auditing