Title: Community Health Worker / Care Coordinator
Reports to: Manager of Care Management
Classification: Individual Contributor
Location:Springfield/Western MA
Job description revision number and date: V, 2.0 10/21/2024

Organization Summary:

Community Care Cooperative (C3) is a 501(c)(3) non-profit, Accountable Care Organization (ACO) governed by Federally Qualified Health Centers (FQHCs). Our mission is to leverage the collective strengths of FQHCs to improve the health and wellness of the people we serve. We are a fast-growing organization founded in 2016 with 9 health centers and now serving hundreds of thousands of beneficiaries who receive primary care at health centers and independent practices across Massachusetts. We are an innovative organization developing new partnerships and programs to improve the health of members and communities, and to strengthen our health center partners.

Job Summary:

As an integral member of the care management team the Community Health Worker (CHW) will have the opportunity to make a profound impact on the lives of individuals living with complex and/ or chronic conditions, many of whom also face multiple barriers accessing care and need support to achieve health care goals. This position requires flexibility and may vary from day-to-day to meet members where they are. Outreach methods may vary based on the needs of the organization and may include telephonic or in-person support in a variety of potential settings such as but not limited to, the community, home, facility, or health center.
In addition to your Community Health Worker role, you will also function as a care coordinator for the Community Partners (CP) at your assigned FQHC, providing integrated care and ongoing coordination of services. You will participate in care team meetings as well as respond to communications from the CPs and health centers. You will assist with problem resolution, managing and maintaining processes and support the planning and coordination of the program and activities.

Responsibilities:

Works under the guidance of the Licensed Care Manager or Program Leaders (Leads, Supervisor, Manager or Director) Conducts initial outreach calls to encourage member/representative and caregivers to participate in care management programs Develop and implement outreach plans in collaboration with team colleagues, based on individual, family, and community needs, strengths, and resources Identify and share appropriate information, referrals, and other resources to help individuals, families, groups and the primary care team meet their needs Gather and combine information from different sources to better understand clients, their families, and communities Initiate and sustain trusting relationships with individuals, families, social networks, and primary care team Use a range of outreach methods to engage individuals and groups in diverse Share community assessment results with colleagues and community partners to inform planning and health improvement efforts Use effective communication skills (bi or multi-lingual preferred) Act as a cultural mediator by educating and supporting providers in working with clients from diverse cultures and help clients and community members interact effectively with professionals to promote health, improve services, and reduce healthcare disparities Addresses language and cultural barriers to care Coaches and guides member/representative to meet both personal and clinical Assists in scheduling appointments on behalf of member/representative Work with individuals, family, community members, primary Care Managers (CMs), and primary care team to address issues that may limit opportunities for healthy behavior. This includes completing Social Drivers of Health (SDOH) screening and other tactics to obtain support for barriers to care Provide care coordination, which may include but not limited to facilitating care transitions, supporting the completion of referrals, and providing or confirming appropriate follow-up Help bridge cultural, linguistic, knowledge and literacy differences among individuals, families, communities, and providers Helps member/representative access community and government-based service agencies including completing paperwork for the member Helps teach the member/representative and/or care giver about symptom response Participates in the integrated care team meetings and rounds as required Complies with reporting, record keeping, and documentation requirements in ones work Use appropriate technology, such as computers, for work-based communication according to C3 and health center requirements 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/ hospitals/community-based locations and or accompany members to appointments as appropriate As needed, cover other areas in person or via telephonic support Other duties as assigned

Care Coordination Responsibilities:

Function as a primary point of contact for the C3 Community Partner providers Build positive relations with external stakeholders including the CPs, health centers, and state agencies Manage your FQHC/APPs Community Partners Roster Make referrals to the community partner program as appropriate. Upload CP Assessments and Care Plans in the EHR

Required Skills:
Experience within the ACOs member population preferred including Medicare/Medicaid member populations Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Providers, Nurses, Social Workers, Pharmacists and other health care teams. Bi/multi-lingual preferred or experience with Language Translation Services Experience working with patients with chronic medical and behavioral health needs. Must be flexible and adaptable to change Demonstrate the ability to work independently Must demonstrate excellent interpersonal communication skills Additional desirable qualities include enthusiasm and passion for helping patients, genuine spirit, kind, and empathetic nature, and one who embraces a go with the flow mentality Experience using appropriate technology, such as computers, for work-based communication, according to C3 and health center requirements. Experience and proficiency with Microsoft Office and online record keeping

Desired Other Skills:
Experience working with members/patients with complex needs highly desired Experience working with homeless member populations Familiarity with the MassHealth ACO program Familiarity with Federally Qualified Health Centers Experience with anti-racism activities, and/or lived experience with racism is highly preferred
Qualifications:
Minimum 2-5 years experience as a Community Health Worker (CHW), Medical Assistant (MA), Engagement Specialist, Care Coordinator or Care Advocate A valid driver's license and provision of a working vehicle
** In compliance with Covid-19 Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law. **