Community Health Worker II- Care Coordinator/ MGH- ICMP!

MGH strives to advance health equity, improve health outcomes, and promote well-being of our primary care patients by addressing health-related social needs, system navigation, and care coordination as standard of care. Community Health Workers (CHWs) are an integral part of achieving these goals. 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.

The CHW Care Coordinator is part of the Integrated Care Management Program (iCMP) team at MGH. The iCMP is a primary care-based care coordination program. It is an innovative program that focuses on improving the health of high-risk medically, psychiatrically, and/or psychosocially complex adult patients. The objectives are to improve quality of care, patient and provider satisfaction, and reduction in overall healthcare costs. This is accomplished through proactive patient outreach, engagement, and care coordination. The CHW role collaborates closely with the interdisciplinary care team to connect patients to resources, improve patients' access to care, and support patients to achieve optimal health and wellbeing. The position requires a high degree of flexibility, independence and willingness to participate in multiple activities and provide support to all members of the iCMP team.

Patient Engagement and Assessment

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  Engage high-risk patients identified for CHW case management telephonically, within MGH, and/or at offsite locations as needed to advance care (community and/or home visit).

  
  
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  Conduct a comprehensive high risk assessement and utilize motivational interviewing to help patients identify their own health goals, support adherence to care plans, and identify and address barriers to medical care.

  
  
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  Collaborate with interdisciplinary primary care team to identify and complete care plan goals over the course of 1-3years.

  
  
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  Provide culturally sensitive services to patients from diverse racial, cultural, and socioeconomic backgrounds; utilize medical interpretation as needed.

  
  

Systems Navigation, Health Coaching, and Care Coordination

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  Provide targeted interventions to a panel of identified patients to help address medical needs and social determinants of health (SDOH) that play a critical role in health outcomes.

  
  
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  Assist patients to navigate healthcare system, including helping patients schedule, obtain transportation, and attend appointments; accompany patients to appointments as needed.

  
  
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  Research and connect patients to community resources related to SDOH needs, including food, housing, transportation, legal services, and other identified needs.

  
  
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  Provide health coaching to support patients to address chronic illness and adopt healthy behaviors to assist with the management of chronic disease.

  
  

Collaboration and Documentation

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  Document care within the patient's electronic medical record.

  
  
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  Collaborate and communicate with iCMP and patient care team via email, telephone, and case conferences.

  
  

• High school diploma or GED required
• Relevant prior work experience, OR associate or bachelor's degree preferred
• Minimum two years of work experience
• Previous work in community settings preferred

• Strong interpersonal skills
• Assessment and problem-solving skills
• Ability to work independently and within a multi-cultural team
• Demonstrated organizational and time management skills
• Demonstrated ability to work effectively and provide advocacy for racially and ethnically diverse populations and communities preferred
• Strong commitment to social justice and health equity
• Experience working as a patient navigator/community health worker preferred
• Strong oral and written communication skills
• Proficient in all Microsoft Office Suite, including Outlook and Excel