Community Health Worker, Care Management

Description

THE ORGANIZATION

North Shore Community Health (NSCH) is a highly accomplished community health organization that prides itself on its compassionate approach to serving the surrounding communities with comprehensive and culturally sensitive care. With a strong commitment to excellence, NSCH provides:

• Comprehensive primary care.
• Dental services.
• Behavioral health care.
• Care management.
• Pharmacy services.
• Substance abuse disorder treatment.
• Nurse care management.
• Insurance enrollment assistance.

NSCH operates service sites at Gloucester, Peabody, and Salem Family Health Centers, ensuring convenient access to care. Additionally, NSCH extends its reach through school-based health centers within the Salem and Peabody School Districts. NSCH collaborates with Bentley Academy, Collins Middle School, Horace Mann School, Bates Elementary School, and the Peabody Learning Academy for behavioral health services.

As a community-based safety net healthcare provider, NSCH actively encourages diversity and welcomes staff members who reflect the rich tapestry of our communities. We highly value the contributions of our team members and offer a wide range of perks and comprehensive benefits. These include health and wellness benefits, tuition reimbursement, loan forgiveness opportunities, and other appealing benefits.

We believe in supporting our employees from day one, and all eligible staff members can take advantage of these benefits right from the start of their employment at NSCH. We aim to foster a supportive and rewarding environment that empowers our team members to provide exceptional care to our communities.

Primary Purpose of Position:

North Shore Community Health (NSCH) is an industry leader in exceptional community healthcare delivery. The Community Health Worker for Care Management (CHW – CM) will provide culturally appropriate health education, counseling, case management, follow up, and advocacy for NSCH patients with complex health needs. The CHW- CM collaborates with the Primary Care Team, ACO team and other staff to help coordinate services and improve access to care with a focus on patients who are identified for care management through ACO programs. The CHW-CM also performs community outreach in order to facilitate linkages with community agencies to address barriers related to social determinants of health.

Essential Functions:

• Provides culturally competent support services      for patients depending on individual needs and preferences. These include but are not limited to:
  1. Provides       education/information/assistance in obtaining access to primary care,       behavioral health care and other human services
  2. Management of urgent non-medical issues       (connecting urgently to social service agencies for example around       housing or food)
  3. Conducts outreach calls to encourage       patients and caregivers to participate in specific health care programs
  4. Conducts and documents relevant patient       assessments as designated by health center and ACO programs. 
  5. Develops and implements outreach plans       in collaboration with team colleagues, based on individual, family, and       community needs, strengths and resources
  6. Uses a range of outreach methods to       engage individuals and groups in diverse settings (for example: phone,       email, text, face-to-face, etc.)
  7. Identifies barriers to care and helps       identify solutions, problem-solving within the health center and with       other agencies, as needed
  8. Provides patient support and advocacy
  9. Initiates and sustains trusting       relationships with individuals, families, social networks and primary       care team
  10. Provides informal supportive counseling       and encouragement
  11. Provides direct assistance with       completion of forms and making appointments
  12. Communicates with patients’ primary care       and/or behavioral health providers
  13. Coordinates and/or provides interpreting       for patient appointments within and outside of NSCH on an as-needed basis
  14. Collaborates with community agencies,       for example, behavioral health community partners and long-term services       and supports, to improve care coordination
• Provides ongoing monitoring, follow-up      and discharge planning, as appropriate, under the direction of the Nurse      Manager, ACO team members, or other care team members. 
• Provides education on chronic disease      management, comprehensive preventive care, and self-management goals as      directed/provided by the PCP, RN, BH provider or other appropriate team      member.
• Ensures access to or develops/maintains      updated community support services and res