Why This Role is Important to Us:

Commonwealth Care Alliance’s Community Health Services (CHS) Department is responsible for addressing health related social needs (HRSN) and social determinants of health (SDOH) for enrollees in One Care (ICO) and Senior Care Options (SCO) plans. Community Health Workers (CHWs) are key members of interdisciplinary care management teams and complement and support each enrollee’s needs, goals, and preferences. The Community Health Worker II is a highly experience and specialized CHW within the Community Health Services Department and ensures that a panel of enrollees overcomes barriers to care and engagement related to social needs. CHW IIs utilize evidence-based practices, key knowledge of community-based resources, recovery-informed principles, and coaching skills to improve CCA enrollee outcomes by impacting care access and utilization, closing of care quality gaps, and optimizing member connection to medical, behavioral health, and substance use disorder resources. CHW IIs play an integral role in reducing high ED and inpatient utilization related to unmet social needs, including housing, food, community resources (e.g. utility support), transportation, and digital literacy. CHW IIs support CCA’s current and future Community Health Services programs and initiatives, including housing programming, community resource engagement, and place-based services.

The CHW II reports to the Community Health Services Manager.

Supervision Exercised:

No, this position does not have direct reports.

What You'll Be Doing:

• CHW IIs are subject matter experts on SDOH and HRSN. CHW IIs assess and educate enrollees in key areas including food, housing, transportation, benefit maintenance, community resources/programs, health/vocational training, and digital literacy. CHW IIs complete SDOH assessment for enrollees and provide appropriate resources, support, and intervention. CHW IIs provide episodic and/or longitudinal support to enrollees based on needs, goals, and preferences. CHW IIs conduct in-person, virtual (telehealth), or telephonic visits with enrollees as needed or as requested.

• CHW IIs support creation of comprehensive and holistic plans of care and contribute to enrollee Care Plans, including adding, updating, and closing out goals pertaining to SDOH and social needs.

• CHW IIs ensure appropriate, comprehensive, and timely documentation of all contacts, outreaches, assessments, and interventions in the Centralized Enrollee Record (CER). CHW IIs communicate orally and via writing with professionalism.

• CHW IIs identify gaps in care pertaining to SDOH that create barriers and result in unmet needs. CHW IIs identify areas of opportunity, as well as defined resources, and collaborate with the Interdisciplinary Care Team to implement appropriate and timely interventions.

• CHW IIs work toward the promotion, prevention, and reduction of health risks, including providing health education in collaboration with an enrollee’s Interdisciplinary Care Team and Primary Care Provider (PCP) or specialty care providers (e.g. behavioral health clinician).

• CHW IIs utilize recovery-centered strategies, harm reduction skills, positive behavioral support techniques, strengths-based approaches, and appropriate boundaries to support enrollees in achieving their stated goals.

• CHW IIs participate in and contribute to weekly team meetings, departmental meetings, individual supervision with the CHS Manager, and other group meetings as scheduled. CHW IIs provide consultation and expertise to colleagues, including other CHWs and members of the Interdisciplinary Care Team.

• CHW IIs complete mandatory clinical, staff safety, and compliance education and training in a timely manner.

• CHW IIs foster mentoring, coaching, and training within the CHS Department. Under the guidance of the CHS Manager, CHW IIs participate in the onboarding of newly hired CHWs via shadow visits and “onboarding buddies,” modeling workflows, role functions, and documentation practices; and promoting CHW core competencies as per the National Association of CHWs (NACHW).

• CHW IIs support CHS Department programs and initiatives, including community engagement and development, topical education and workshops (e.g. housing, digital literacy), place-based services, grant-related activities, and quality improvement initiatives. CHW IIs participate in committees and work groups that promote clinical excellence and advance CCA’s mission, values, and business objectives.

• CHW IIs are mandated reporters and are expected to report suspected abuse or neglect via appropriate channels and reporting procedures, including CER documentation and required internal or State processes.CHW IIs perform other duties as assigned to support enrollee and business needs.

• All CCA employees:

• Are expected to demonstrate integrity by working with passion, commitment, and honesty, acting in the best interests of colleagues and enrollees.

• Approach work in a collaborative and caring manner and interact with insight, sincerity, and compassion.

• Demonstrate accountability by delivering on commitments, owning mistakes as well as successes, and contributing to an empowering and innovative environment where the focus is on solving problems and learning from errors.

• Recognize, respect, and celebrate diversity in all forms.

• Strive for excellence in the fulfillment of CCA’s mission via quality, innovation, and continuous learning.

• Demonstrate initiative, flexibility, and openness to change.

• Represent CCA and its clinical affiliates with professionalism.

• Keep current and proficient with necessary skills and knowledge; self-identify training and development needs relevant to work and responsibilities.

• Adhere to all applicable compliance requirements, including but not limited to:

• Complete annual compliance training in a timely manner; promote and enforce the CCA compliance program

• Review the Code of Conduct at least annually and adhere to the content within

• Adhere to CCA policies and procedures

• Promptly, in good faith, report any instances of suspected fraud, waste, or abuse; suspected privacy and/or security incidents; or any other compliance concerns identified

• Ensure confidentiality of HIPAA-protected communications, as well as enrollee and company proprietary information Working Conditions: Work locations include residential and community sites.

• This is a grant funded position.

What We're Looking For:

Qualifications:

• Bachelor’s Degree OR Associate’s Degree with 2+ years of additional relevant experience required,Graduate Level Degree (e.g. MSW, MA, MS) preferred

• CHW Certification strongly preferred

• Doula Certification preferred

• Housing Navigator/Specialist preferred

• Health/Wellness Coach Certification preferred

• 5+ years in community or outreach settings working with clients who have complex needs, including medical, social, behavioral health, or substance use required,5+ years in health plan or managed care settings preferred

• Ability to communicate and document work professionally and in a timely manner; ability to utilize SBAR communication

• Ability to provide compassionate and empathic care to enrollees with complex needs

• Ability to work in a dynamic and innovative healthcare environment; ability to manage change and multiple priorities

• Demonstrated understanding of SDOH and HRSN and the role they play in enrollee care; demonstrated expertise on local resources and benefits and how to access them

• Demonstrated experience with, or ability to learn, technological support tools including virtual/telehealth platform and video conferencing

• Demonstrated proficiency with Microsoft Office products (Word, Excel, Outlook)

• While performing the duties of this job, the employee is required to sit, stand, use hands to finger/handle/feel, reach with hands or arms, talk, and hear. The employee is occasionally required to walk, stoop, crouch, kneel, or crawl. The employee must lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus. Reasonable accommodations may be made to enable individuals with disabilities to perform essential job functions.

• CHW II is a mobile position. CHW IIs must be willing and able to travel to enrollees’ homes or community locations as required, in addition to working in an office environment. Must be willing and able to travel to CCA offices and to other CCA sites across Massachusetts as required. Valid driver’s license with no restrictions and reliable access to a vehicle required.

• English required,Bilingual preferred

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.