Job Description

Location: Northeast Massachusetts (Hybrid)Organization Summary:Community Care Cooperative (C3) is a 501(c)(3) non-profit, Accountable Care Organization (ACO) governed by Federally Qualified Health Centers (FQHCs). Our mission is to leverage the collective strengths of FQHCs to improve the health and wellness of the people we serve. We are a fast-growing organization founded in 2016 with 9 health centers and now serving hundreds of thousands of beneficiaries who receive primary care at health centers and independent practices across Massachusetts. We are an innovative organization developing new partnerships and programs to improve the health of members and communities, and to strengthen our health center partners.Job Summary:The Community Health Worker (Transitions of Care Program) will be a member of a team of social workers, physicians, pharmacists, community health workers, and program coordinators, you will have the opportunity to make a profound impact on the lives of people living with complex and/ or chronic mental health conditions, many of whom also face multiple barriers to accessing care and adhering to a provider’s treatment plan. The CHW works as an extension of the clinical care team. You will connect with your patients in person, on the phone, in the hospital, and in the provider’s office. You must be prepared to work from home office, hospital, Health Center, provider’s office setting, within patient’s homes, or in the community.Responsibilities:Works under the guidance of the Behavioral Health TOC Social Work Care ManagerConducts initial outreach calls to encourage patients and caregivers to participate in care management programsMeet with members in person in the community and/or at the health centersEngages with patients who need assistance with psychiatric and/or substance use recovery care needsAddresses language and cultural barriers to careCoaches and guides the patient to meet psychiatric and other clinical goalsHelps teach the patient and/or care giver about psychiatric and/or substance misuse symptoms response plansAssists in scheduling appointments on behalf of patients and reminds patients of their upcoming visitsAccompanies patients to their visits as neededCompletes Social Determinants of Health AssessmentsHelps patients access community and government-based service agencies including filling out paperwork for the patientArranges transportation as needed (PT1)Establishes relationships with community agencies, resources, and supports that are relevant to the Medicaid populationAssists with Medicaid applications, food and nutrition benefits, housing applications, coordinating transportation, etc.Travels to engage members at their homes or in the communityParticipates in the integrated care team meetings and rounds as requiredMaintains accurate, timely documentation in electronic systemsProvides team support as needed Required Skills:Demonstrated success in working as part of a multi-disciplinary team including communicating and working with providers, nurses, and social workersExperience working with patients with chronic and mental health and/or substance misuse needsMust be flexible and adaptable to changeAbility to work independentlyExcellent interpersonal communication skillsAdditional qualities that would be a good fit for our team include enthusiasm and passion for helping patients, genuine spirit, kind and empathetic natureExperience working with Electronic Medical Records and healthcare systemsExperience and proficiency with Microsoft Office and online record keepingDesired Other Skills:Familiarity with the MassHealth ACO programFamiliarity with Federally Qualified Health CentersExperience with anti-racism activities, and/or lived experience with racism is highly preferredBi-lingual (preferred)Qualifications:Experience working with Medicare, Medicaid and/or Special Needs populationsA valid driver's license and provision of a working vehicle** In compliance with Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law. **

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