AmeriCorps Primary Care Connector

4 weeks ago


East Boston, United States East Boston Neighborhood Health Center Full time
AmeriCorps Primary Care Connector

The AmeriCorps Primary Care Connector (PCC) will have the unique opportunity to make a profound impact on the lives of underserved individuals and families acting as an extension of the clinical team.  The PCC will actively engage patients living with complex and/or chronic medical and behavioral health conditions in their care through outreach, education, and engagement in preventative cancer screenings as well as screening patients for Social Determinants of Health needs, identifying appropriate support services and navigating access barriers.

  • Complete Social Determinant of Health screenings 
  • Determine eligibility for community resources.
  • Provide assistance to patients identified barriers (ie. language, literacy)to complete forms such as: Disability, DTA benefits, Food assistance, transportation
  • Act as a resource for Primary Clinical Care teams for community resource information and educate how to access on internal database
  • Track all patient encounters in EPIC medical record system and identified tracking systems
  • Close the chronic disease and preventative care gaps through close examination of care gap specific patient lists and review of associated medical charts.
  • Use motivational interview skills to determine patients’ motivation and confidence to close gaps in care.  
  • Provide over the phone education about cancer screening options, identify barriers to screening and assist as appropriate with breaking down barriers and scheduling.
  • Provide follow up support for patients who are referred for cancer screenings outside of the health center
  • Update health maintenance and care gap alerts in EPIC
  • Uses MyChart and texting platforms to communicate with patients
  • Monitor all cancer screening results (normal, abnormal and incomplete) and initiate follow up.
  • Participate in professional development and team trainings to further the understanding of community resources and the intersections of social justice and community health work.
  • Participate in planned team community service activities at local Community Based Organizations


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