This position will contribute to these MGH efforts through collaboration with the Center for Community Health Improvement (CCHI) and Performance Analysis & Improvement Unit (PAI) teams. CCHI oversees a team of Community Health Workers. CHWs are trusted members of the community who help patients improve access and coordinate their health care. CHWs have the skills and experience to understand their patients’ circumstances. By building trusting relationships and walking alongside their patients, CHWs help address medical and psychosocial needs in order to promote self-efficacy, help patients meet their goals, and improve health outcomes.
- Refer to internal or external case management services within the practice when other issues are identified (i.e. food insecurity, domestic violence issues, etc.)
- Using patient registries, identify and monitor high-risk patients with medical and/or psychosocial conditions to provide community health services
- Work with primary care providers to reinforce provider care plans and health education messages the importance of follow-up care, medication adherence, routines of self-care, etc.
- Provide advocacy, patient education and support in accessing community-based and hospital-based programs
- Support patients and families in setting and following through with clinical goals to manage their asthma and lifestyle goals to address how their weight is impacting their health.
- Assist patients in organizing their records, making follow up appointments, filling their prescriptions, understanding past medical history
- Works as an effective team member of the CCHI and PAI population health management program to provide health coaching and care coordination to patients and families
- Engage patients telephonically, via home visit (or “porch” visit during COVID), and in the PCP office with occasional accompaniment to medical appointments and community services
- Ability to persuade, influence and enlist others’ support in accomplishing objectives
- Spanish and/or other language fluency [Portuguese, Haitian Creole, Arabic] desirable
- Ability to connect and engage with Black / African Community desirable
- Proficient in Microsoft Applications, including MS Word and Excel
- High school diploma or GED required.
- Relevant experience in the community or Bachelor’s degree preferred; preference for Psychology/Social Work/Public Health or related field.
- Minimum 2 years of working experience. Previous work in community settings or promoting healthcare behavior change is preferred (i.e.: patient navigator/community health worker).
- Ability to identify problems, think creatively, and devise innovative solutions
Vacancy Type: Full Time
Job Location: Chelsea, MA, US
Application Deadline: N/A