Job Summary:
Commonwealth Care Alliance's (CCA) Care Delivery programing is responsible for providing care delivery and care management to a specific panel of high risk and complex people. Founded in 1977, the practice known today as CCA Primary Care is a Massachusetts based provider nationally recognized as a leader in the care of individuals facing complex challenges. Today, the impact of our care delivery program is wider than it has ever been – serving over a thousand of individuals across the state. Join a team committed to serving complex individuals with the best possible care in a unique, comprehensive and quality focused model. We are a specialized interdisciplinary team engaged in collaborative care with a wide range of resources. Our goal is to improve the lives of the people we serve and help keep them at home, by providing best-in-class disability competent care.
Within Care Delivery, the Community Health Worker (CHW) functions as an integral member of an interdisciplinary team for care delivery and care coordination for the most complex medical and behavioral health patients. The CHW participates in aiding the patients around all social determinants of health (SDOH) needs in the context of the patient centric individualized plan of care. The CHW uses evidence-based resources, knowledge of community-based care and support, trauma/recovery skills, and health coaching/education to influence the outcomes of assigned patients by impacting acute care utilization, ensuring optimal treatment and closing gaps in care through connecting patients with community supports.
The CHW will help the patient to access the best types of care for their needs including community long-term services and supports. They will focus on reducing gaps in preventive care interventions, optimize patients' engagement with primary care, behavioral health, and substance use services. The CHW will play an integral role supporting patients with frequent utilization of Emergency Departments and acute admissions with the goal of identifying SDOH factors that may be contributing, and partnering with the patient to identify more efficacious and appropriate supports that empower the patient and meet his/her needs.
This position reports to a Care Delivery Clinical Manager
Essential Functions
· The primary function of the Care Delivery CHW role is delivering care to CCA’s most complex patients, providing care management and care coordination support, and collaborating with external providers with the goal of delivering comprehensive care.
· Essential Duties Include – best in class patient care; clear, concise, and effective communication and documentation; and interdisciplinary collaboration with a variety of stakeholders internally and externally.
· Patient Care:
· Engage in regular assessments pertaining to patients Social Determinants of Health
· Conduct visits/outreaches to patients telephonically, virtually, or in-person at regularly scheduled intervals.
· Conduct urgent follow-ups to address patients’ significant social needs (medical or behavioral health)
· Conducts coaching and education towards the promotion of wellness, and the prevention and reduction of health risks.
· Supports the health education needs of the patient in collaboration with the interprofessional care team and PCP
· Assess health risks, identify gaps pertaining to SDOH issues that create barriers to care and/or contribute to unmet needs
· Conducts closed loop communication with patients’ external providers including the PCP and CCAs interprofessional team to identify areas of opportunity, define resources, and coordinate implementation of care plan.
· Collaborate with patients on SDOH goals in care plan and provide support and education for key care management or coordination decisions
· Support efforts to decrease hospitalization utilization such as admissions, readmissions, and emergency department use
· Supports patient retention and connection to Medicaid and Medicare benefits
· Conducts health education on key quality measures including preventative health maintenance and routine medical screenings
· Assists patients in obtaining or stabilizing housing, finances, food, utilities, educational/vocational opportunities, and community supports
· Engages with community agencies and service providers to build relationships to support patients
· Addresses issues regarding substance misuse/abuse, if indicated, in conjunction with Behavioral Health Clinicians and supports
· Uses recovery strategies such as motivational interviewing, harm reduction, positive behavioral support techniques, limit setting, and strengths-based approaches to support patients in attaining stated goals
· Provides 1:1 health education to patients regarding chronic disease self-management to prevent and manage health conditions and encourage development of healthy behaviors/habits
· Serve as a tech literacy coach and support enabling, coaching, and supporting patients with technology to optimize care delivery and care coordination. At times, the CHW will provide 1:1 support for patients in virtual visits with licensed clinicians.
· Documentation and Accountability:
· Documents all visits with focus on clear, comprehensive, and concise charting. Must be able to document in English.
· Completion of all tasks within appropriate timelines as outlines in Scopes of Practice and CCA Guidelines.
· Comply with organization policies and procedures.
· Communicates clear loop closure to HICM interdisciplinary care team and plans for patient centric follow-ups as indicated.
· Identify and initialize a plan to resolve areas of opportunity to meet Key Performance Indicators (KPIs).
· Maintain patient and employee confidentiality.
· Actively participates in the evaluation of own performance and progress
· Provide input to patients care team on key care management/care coordination decisions.
· Interdisciplinary Team Collaboration:
· Proactively and collaboratively work with patient’s Primary Care Provider (PCP) and other external providers to ensure a cohesive medical treatment plan is delivered.
· Conduct on-going and effective collaboration and communication with external providers, including but not limited to Primary Care staff, specialty services, LTSS coordinators, Aging Service Access Points (ASAPs), visiting nurse services, care attendants, patient designated contacts, and next of kin.
· Conduct on-going and effective collaboration and communication with interdisciplinary team including but not limited to, Health Plan Care Team, Community Advanced Practice Clinicians, Community Health Workers, Community Behavioral Health Clinicians, Medical Directors, Palliative Care Team, Psychiatric services team, Rehab Team, Crisis Response workers, Patient Services representatives, administrative staff, and CCA Leaders.
· Participates in weekly interprofessional care team meetings and ad hoc case conferences as needed
· Provides consultation and support to other patients of CCA Care Team
· Participates in ongoing education and training to improve skills and role-specific certifications or specialization.
· Participates in CCA quality improvement efforts
· Assists CCA management and leadership with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects
· Participates in committees and workgroups that promote clinical excellence and help to advance CCA’s mission and business objectives
· Provides clinical care to patients via telehealth technologies (i.e., video, chat) for clinically appropriate clinical care and care management services
· Other duties as assigned
· Perform any other job related duties as requested.
Education and Experience
· Associates required
· Bachelor's preferred
· Equivalent years of relevant work experience may be accepted in lieu of required education
· Three (3) years 3 + years experience in community-based care required
· Five (5) years 5+ years of minimum experience working in outreach or in the community with patients who have high behavioral health needs and high medical complexity. Experience with electronic medical record strongly preferred (eCW) preferred
Competencies, Knowledge and Skills
· Excellent written and verbal communication skills.
· Working knowledge of Microsoft Office applications
· Excellent organizational skills.
· Ability to utilize an Electronic Medical Record
· Ability to use on-line training platforms
· Demonstrated understanding of Mass Health benefits
· Ability to review welcome packets and obtain consent forms
· Demonstrated understanding of LTSS
· Proven skills and judgment necessary for independent decision making.
· Strong organizational, time management and problem-solving skills.
· Ability to function effectively within a multi-disciplinary team.
· Effective oral and written skills. Strong interpersonal and customer relations skills.
· Comfort working with DME vendors, verifying accuracy of products and quotes.
· Demonstrated proficiency with Microsoft Excel, Word, and Outlook
· Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.
Licensure and Certification
· CHW Certification preferred
· Housing Specialist preferred
· Certified Application Counselor (CAC) preferred
· Certified Addiction Recovery Coach (CARC) preferred
· Health/Wellness Coach Certification preferred
· Must have valid driver's license, vehicle and verifiable insurance. Employment in this position is conditional pending successful clearance of a driver’s license record check. If the driver’s license record results are unacceptable, the offer will be withdrawn or, if employee has started employment in position, employment in this position will be terminated
· To help protect our employees, members, and the communities we serve from acquiring communicable diseases, Influenza vaccination is a requirement of this position. CareSource requires annual proof of Influenza vaccination for designated positions during Influenza season (October 1 – March 31) as a condition of continued employment. Employees hired during Influenza season will have thirty (30) days from their hire date to complete the required vaccination and have record of immunization verified.
· CareSource adheres to all federal, state, and local regulations. CareSource provides reasonable accommodations to qualified individuals with disabilities or medical conditions, sincerely held religious beliefs, or as required by state law to enable the employee to perform the essential functions of the position. Request for accommodations will be completed through an interactive review process.
Working Conditions
· • This position requires in person visits to patients in their homes and will support patient across various locations. • This position requires travel to CCA sites and offices per required need for various team meetings. • The job has in-person contact with CCA members or patients as part of the job duties. • Job is not a clinical role and services are delivered in the patient’s home.
· Over 50% (Mobile) Routine travel required
Background Check
Employment in this position is conditional pending successful clearance of a criminal background check. If the criminal background results are unacceptable, the offer will be withdrawn or, if employee has started in position, employment in position will be terminated.
Compensation Range:
$41,200.00 - $66,000.00
CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Hourly
Organization Level Competencies
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
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Brand=Commonwealth Care Alliance
