Community Health Worker, Population Care Management - Lynn

Site: North Shore Medical Center, Inc.

 

At Mass General Brigham, we know it takes a surprising range of talented professionals to advance our mission—from doctors, nurses, business people and tech experts, to dedicated researchers and systems analysts. As a not-for-profit organization, Mass General Brigham is committed to supporting patient care, research, teaching, and service to the community.  We place great value on being a diverse, equitable and inclusive organization as we aim to reflect the diversity of the patients we serve.

At Mass General Brigham, we believe a diverse set of backgrounds and lived experiences makes us stronger by challenging our assumptions with new perspectives that can drive revolutionary discoveries in medical innovations in research and patient care. Therefore, we invite and welcome applicants from traditionally underrepresented groups in healthcare — people of color, people with disabilities, LGBTQ community, and/or gender expansive, first and second-generation immigrants, veterans, and people from different socioeconomic backgrounds – to apply.

 

The Mass General Brigham Medical Group is a system-led operating entity formed by Mass General Brigham to deliver high-quality, low-cost, innovative community-based ambulatory care. This work stems from Mass General Brigham’s unified system strategy to bring healthcare closer to patients while lowering total healthcare costs. The Medical Group provides a wide range of offerings, including primary care, specialty care, behavioral and mental health, and urgent care, both digitally as well as at physical locations in Massachusetts, New Hampshire, and Maine. The group also offers outpatient surgery and endoscopy, imaging, cardiac testing, and infusion. We share the commitment to delivering a coordinated and comprehensive experience across all locations, ensuring the appropriate level of care is available to every patient across our care delivery sites.
Our Community Health Workers (CHWs) are integral and trusted members of the community helping our high-risk patients who are receiving care at NSPG and Salem Hospital receive the services they need to achieve an optimum quality of life. This high-risk patient population presents a unique set of challenges, including higher rates of mental illness and substance abuse, and are often harder to contact and engage, as well as having weaker ties to their primary care practice. The CHW acts as a bridge between our primary care teams and our high-risk patients, improving their access to and utilization of healthcare services.

 

Job Summary

We are seeking a full-time, compassionate Community Health Worker to join our NSPG Community Health Worker team! This individual will support patients around the Massachusetts North Shore area of Salem, Lynn, and Swampscott, MA. The typical schedule will be Monday-Friday 8:00 am-4:30 pm (flexible) consisting of 3 days on-site at our practice located at 480 Lynnfield Street, Lynn, and 2 days remote. The Community Health Worker is expected to meet patients at our office location in addition to out in the community.
Although a CHW is not in a clinical role, having the capacity to learn basic clinical concepts in order to identify when a referral to a licensed clinician is appropriate is an important skill. The Key Functions of the Community Health Worker are:
• Provides community health services to high-risk patients facing medical and psychosocial challenges, including structured assessments and goal setting.
• Supports identified patients with improved blood pressure control through coaching.
• Attends ongoing education and training, including self-directed learning, to enhance service delivery.
• Motivates and supports patients in achieving their health goals through home visits, hospital meetings, and follow-up calls.
• Addresses patients' Social Determinants of Health (SDOH) needs by connecting them to essential resources in the community. This includes linking patients to services such as housing assistance, food programs, transportation, and other local support that can significantly impact their overall well-being.
• Documents patient encounters meticulously and collaborates with care teams to ensure comprehensive patient care and advocacy.

Due to the hybrid nature of the role, we ensure that our employees receive the required technology and training to be proficient and independently productive in all job responsibilities regardless of work location. For the remote workdays, employees are responsible for designating a workspace within the remote work location that is private, safe, ergonomic, and free from distractions for all hours worked.

 

Qualifications

Required:

• Local community residents with good knowledge of the resources available within the community.