Summary:

Work as part of the health care team to provide comprehensive, coordinated Community Health Worker (CHW) interventions in accordance with the Massachusetts Board of Certification of Community Health Worker core competencies as part of a patient centered health care home for Health Center patients.

Essential Duties & Responsibilities:

• Bilingual in Spanish and English or English and Portuguese is strongly preferred
• Conduct psycho-social assessments with patients referred for Community Health Worker interventions in accordance with Health Center policies, procedures and protocols.
• Provide basic education, screening, brief intervention and/or facilitate referrals to other health center or community-based resources in accordance with applicable health center protocols for:
• HIV, STD, Hepatitis Chronic Disease, including Asthma, Diabetes, Hypertension and other targeted chronic disease
• Healthy Weight Management
• Financial Management, Depression, Domestic Violence, Substance Abuse including Tobacco
• Prenatal/Postpartum, Pediatric/Parenting Education
• Provide health system education and advocacy to assist patients in navigating the health care system.
• Provide assistance and support (including connecting to appropriate resources) relative to Benefits and insurance
• Health Care, Housing, Transportation, School/Education, Jobs/Employment, Childcare, Food Security
• Participate in population-based projects that enhance retention in care, self-management, treatment adherence, and compliance with accepted health care standards of care.
• Follow-up with provider-identified patients to further assess and address psycho-social barriers that limit the patients’ engagement in their care.
• Participate in assigned community based activities, including outreach to potential new patients and connecting them to care and services.

Additional Job Functions:

• May participate on community, city-wide or statewide committees as a representative of the health center when assigned by supervisor
• May be required to perform more intensive specialized services in the following areas, including: Behavioral Health-process referrals, identify resources, create linkages, connect patients
• Health Insurance Application and Enrollment- if certified
• Refugee Group Sessions and Preventive Health Work with new refugees
• HIV, STD, Hepatitis Counseling and Testing
• Assisting patients leaving Corrections to connect with care
• Intensive Treatment Adherence Monitoring for diseases such as HIV/Hepatitis
• Prenatal-Postpartum Basic Education, Referrals, Linkages, Connection to OB practice and f/u care
• Pediatric/Parenting Education, Adolescent Wellness
• Chronic Disease, including Asthma, Diabetes, Hypertension and other targeted chronic disease
• Perform other duties as required by the Program Manager and/or Department Director.

Critical Demands of the Job:

• Utilizes the following techniques in conducting CHW interventions: self-management, motivational interviewing, teach back, and other patient engagement and retention techniques.
• Works in the clinical area as part of the integrated health care team, as assigned.
• Conducts home visits in accordance with CHW protocols and as assigned by supervisor.
• Supports a work environment that is responsive and sensitive to the needs of a diverse staff and clients and communicates effectively with patients and colleagues.
• Contributes and is an active part of a positive and professional team, supporting our Mission.
• Works within an outpatient office setting and community outreach setting.
• Documents in electronic health record or other assigned recordkeeping format according to health center protocols.
• Functions within flexible work schedule as assigned by site and supervisor and as required by the job.
• Participates in on-site and off-site continuing education programs and in-service trainings to meet CHW certification, funding, or regulatory requirements and to meet the needs of the community.

Required Qualifications:

• High School Diploma or equivalency
• Minimum 2-years work or volunteer experience in human services or healthcare with demonstrated knowledge of or ability to work with and/or within the targeted community
• With limited exceptions approved by the supervisor in advance, a CHW is expected to have a valid U. S. Motor Vehicle License and reliable transportation to travel to/from outreach activities, as they may be assigned from time to time. If the CHW will also be assigned to transport patients, the CHW must provide proof of state-mandated personal Motor Vehicle insurance.
• Demonstrated technical experience with Microsoft Word, Excel (or similar databases)

Preferred Qualifications:

• Relevant undergraduate degree
• Knowledge of applicable state, federal, and/or local regulations and community resources.
• Bilingual in English and other language identified by the Health Center’s as being a language-of-need.

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