Community Health Worker, generalist

General Description:

The Community Health Worker plays a critical role in the health outcomes of patients and community members experiencing social and medical vulnerabilities. The Community Health Worker will serve as a "linkage" between the patient, the health center's clinical care teams, and community-based resources to support patients in addressing social, cultural, environmental, and behavioral factors affecting their health. The Community Health Worker will collaborate with interdisciplinary teams to provide thorough social needs screening and care coordination, as well as proactive tracking and outreach to reduce gaps in care. In addition, the Community Health Worker will facilitate a variety of culturally and linguistically appropriate services, including community outreach and educational initiatives to support the agency's mission to eliminate health disparities through evidence-based, culturally-responsive health promotion programming.

Reports to: Project Manager

Supervises: N/A

Salary/Status: Non-Exempt

Hours: 40 Hours/Week

Note: This position is grant-funded; this is a 1- to 2-year opportunity with possibility of renewal and sustainability depending on performance, funding, and departmental needs.

Minimum Requirements:

* Oral and written fluency in English (fluency in another language a plus, such as Spanish, Arabic, Russian, Vietnamese, Nepali, Somali, or Swahili).
* Associate's or technical degree/certification in a health, human services, or education field, OR equivalent professional or lived experience.
* Holds Community Health Worker certification, OR willing to obtain training and certification upon hire (offered onsite during work hours at no cost).
* Ability to independently and effectively balance and prioritize daily tasks, including caseload management, visit documentation, social determinant of health screening, pre-scheduled client visits, walk-in visits/warm handoffs, community outreach, home visits (following public health safety protocols), special projects, and occasional trainings, webinars, and meetings.
* Understanding of complex medical, social, cultural, and environmental challenges commonly experienced by individuals and communities who seek community health center services.
* Ability to assist individuals with a compassionate and professional demeanor, and to exercise patience and tolerance with individuals who are confused or frustrated.
* Ability to exercise cultural sensitivity when providing care to patients representing diverse cultures, ethnicities, religions, sexual orientations, gender identities, socioeconomic statuses, educational backgrounds, worldviews, health beliefs, literacy levels, and languages.
* Excellent interpersonal communication skills and ability to build effective working relationships with diverse client populations, medical staff, interpreters, and community partners.
* Willing to provide care coordination, support, and information regarding sensitive health care needs, such as behavioral health, substance use disorder, reproductive health, LGBTQIA+ health, domestic violence, and infectious disease.
* Comfortable and willing to facilitate group-based educational activities and to represent agency at public engagements, including health fairs, mobile clinics, radio interviews, press conferences, and community events.
* Ability to listen actively, demonstrate responsiveness to team needs/requests, and integrate feedback thoughtfully and promptly.
* Ability to draw on knowledge, logic, internet resources, and training materials to problem-solve independently.
* High reliability and commitment to adhere to designated work hours/tasks.
* Ability to respond to provider and team requests in a timely manner.
* Ability to maintain an organized, clean, and professional workspace.
* Ability to practice discretion and maintain absolute compliance with state, federal, and internal policies when handling confidential client information.
* Ability to navigate and utilize web browsers and Microsoft Office applications, and knowledge of or willingness to learn how to interface efficiently with databases, Electronic Medical Record systems, and other digital tools.
* Personal transportation to travel to occasional out of-town trainings, meetings, and outreach engagements.
* Flexibility to conduct outreach engagements on occasional weekends and evenings.
* Ability to work full-time, on-site, and/or remote (per health center policy) to deliver direct patient services, including at COVID-19 vaccination and testing sites.

Principle Responsibilities and Duties:

* Provide thorough social needs screenings to assess patient barriers to care, with a goal to address social, cultural, environmental, and behavioral factors affecting their health.
* Provide care coordination by serving as a "linkage" between the patient, the health center's clinical care teams, and community-based resources. Care coordination may include:
* Assistance with patient registration, scheduling, and referrals.
* Navigation to ensure patient access to services and programs within the health center.
* Navigation to ensure patient access to community-based resources and specialty medical services.
* Resolution of barriers affecting patient access to care, such as transportation assistance, patient reminders, and emotional support.
* Support to follow through with specialty referrals, follow-up visits, and other provider recommendations.
* Provide and document in-person, telemedicine, and home visits as appropriate.


* Utilize patient registries to provide proactive tracking and outreach to engage patients in routine screenings and other health care services.
* May be designated to support specific medical providers, departments, and specialty clinics as needed.
* Provide informal health education to coach patients in effective management of chronic health conditions and motivate patients to be active participants in their health.
* Facilitate group-based educational workshops focused on chronic disease prevention and management.
* Support the delivery of wellness programs, such group-based or individual physical activity, nutrition, and stress management classes.
* May conduct home visits in alignment with agency protocol.
* Utilize existing CHW resources to guide patient care, such as resource databases and established internal workflows.
* Continuously expand knowledge and understanding of community resources and services, public health prevention practices, and evidence-based intervention programs.
* Document activities, care plans, and results in appropriate data collection tools and/or Electronic Medical Record in a clear and concise manner.
* Engage in regular clinical supervision with designated supervisor or other CHW/Care Coordination leadership in the health center.
* Receive and integrate constructive feedback to facilitate on-going growth and/or career development opportunities.
* Community Health Workers may be assigned to specialty program areas (e.g., Wellness, Women's Health, COVID-19 Response, ACO Care Management) based on expertise, interest, and/or organizational need.
* Conduct community outreach at health fairs, mobile clinics, radio interviews, press conferences, and community events.
* Participate in frequent meetings and trainings, including Massachusetts Community Health Worker Certification Training, and other certification trainings which may include asthma home visiting, chronic disease self-management facilitation, domestic violence advocacy, family planning counseling, and motivational interviewing.

Working Conditions:

* This position may require the ability to work long and arduous hours.
* This position requires the ability to use a computer workstation, viewing a CRT.

JOB CODE: 10