Community Health Worker, BILHPN MassHealth ACO

Job Type: Regular

Time Type: Full time

Work Shift: Day (United States of America)

FLSA Status: Non-Exempt

When you join the growing BILH team, you're not just taking a job, you're making a difference in people's lives.

BILHPN Masshealth-ACO is responsible for improving coordination of patient care, reducing unnecessary hospitalizations and readmissions, emergency department visits and revisits, and reducing total cost of care over time. BILHPN Masshealth ACO will provide services in collaboration with contracted Managed Care Organizations (MCOs) as well as Community Partners (CPs) for Behavioral Health (BH) and Long Term Services and Supports (LTSS), Health Related Social Needs (HRSN) Providers/Community Based Organizations (CBOs) as appropriate.

Working under the direction of the Social and Behavioral Services Program Manager, the BILHPN MassHealth ACO Community Health Worker (CHW) will work directly with members, families, and caregivers to perform outreach and engagement and to assist with care coordination, care management, and care transition functions and activities for assigned ACO members. The CHW will work with at-risk members and families in all settings including their homes, to assess the member's health care needs, social service needs, and social obstacles to health. The CHW will connect members to appropriate, available providers and community resources, with goals of improving the member's quality of life and increasing their access to health care - related programs and services at the appropriate time and in the most appropriate settings.

Job Description:

Essential Duties & Responsibilities (including but not limited to):

• Engages members who meet high/moderate risk complexity eligibility via multiple modalities

• (face to face; telephone; email; text) at a frequency determined by member need and as agreed upon by the member, working under the direction of a Behavioral Health or Social Services manager

• Documents all activities in relevant electronic record, with follow-up schedule clearly indicated

• Screens and supports enrollment of eligible patients into Flexible Services, Social Service Organizations as appropriate

• Provides active, non-judgmental listening and, where applicable, conducts motivational interviewing

• Facilitates scheduling of Comprehensive Assessments, face-to-face whenever possible and appropriate

• Identifies member social needs and cultural preferences, including arranging for interpreter services as needed

• Contributes to member Comprehensive Assessments by gathering and documenting information from the member, family, health care and social service providers and other stakeholders, as assigned

• Ensures that the member understands their rights and how to file any complaints or grievances

• Facilitates communication and coordination between the member or designated representative and member's PCP and other healthcare providers, including BH and LTSS CPs

• Facilitates and coordinates member referrals to community social service providers as indicated and as agreed to by the member

• ? Assists members to access further treatment, self-help groups, housing, community based programs and other social services related to medical /behavioral health and other care needs

• Provides educational materials on mental health and substance use disorders and treatment options to the member and his/her family or natural supports, as directed by the member's PCP, Social Worker, or RN Care Manager

• Attends Care Management Team meetings and case reviews as scheduled or as requested by Social Worker, RN Care Manager, or PCP

• Develops and maintains collaborative relationships with community- based organizations in the ACO Service Area

• Coordinates logistics to support member's Care Plan adherence, such as appointment reminders, transportation, and childcare arrangements, as needed

• Assists member to identify and address barriers to compliance with their Care Plan and/or achievement of their Care Plan goals.

• Provides Emergency Department visit support, as directed

• Facilitates member's timely access to their PCP or other providers

• Supports safe transitions of care for members moving between care settings

Organizational Requirements:

• Maintains strict adherence to Beth Israel Lahey Health Confidentiality policies and HIPAA requirements.

• Incorporates Beth Israel Lahey Health Standards of Behavior and Guiding Principles into daily activities.

• Complies with all Beth Israel Lahey Health Policies and Procedures, including policies and procedures related to member outreach and engagement, care coordination, care management, and care transition functions and activities.

• Maintains current and accurate documentation within the ACO care management electronic record, per established organizational policies and procedures.

• Complies with behavioral expectations of the Department and Beth Israel Lahey Health.

• Maintains courteous and effective interactions with colleagues, members, and all others.

• Demonstrates an understanding of his/her job description, performance expectations, & competency assessment.

• Demonstrates a commitment toward meeting and exceeding the needs of Beth Israel Lahey Health's customers and consistently adheres to Customer Service standards.

• Participates in departmental and/or interdepartmental quality improvement activities.

• Participates in and successfully completes mandatory education and training, as assigned.

• Performs all other duties as needed or directed to meet the needs of the department.

Minimum Qualifications:

Education:

• High School Diploma or General Education Diploma (GED) required.

• Associate's degree or Bachelor's degree in psychology, social work or related human services field from an accredited college or university a plus

Experience:

• 1 year experience in community-based social services or behavioral health support program required; 2-3 years' experience preferred

• Candidate may be a licensed clinician who does not have the credentials to practice independently (e.g., LPN, LSW, or degree in a related health care field)

Skills, Knowledge & Abilities:

• Must have basic knowledge of medical/health care delivery environment and medical terminology

• Working knowledge of health plans and benefits a plus

• Demonstrated ability to work collaboratively within a multi-disciplinary team

• Demonstrated strong communication skills (both written and verbal)

• Self-directed with demonstrated strong time management and organizational skills

• Must demonstrate appropriate boundaries regarding confidentiality and personal relationships

• Strong ability to evaluate what is needed by each individual and adjust approach accordingly, using a strength-based, member-centered approach to care planning

• Strong problem - solving ability and critical thinking skills

• Experience with local community resources and navigating mental health and/or substance use disorder treatment systems preferred

• Ability to utilize computers, web-based applications, and MS Office application required

Other Job Requirements :

Schedule Requirements: Some flexible work hours to accomplish member outreach and engagement at times when members are reachable; this may involve some early evening hours or later work days.

Travel Requirements: Must have a current, valid driver's license and own transportation. Travel and an ability to meet with members served in a variety of outreach settings is required.

Key Relationships:

• Reports to Social services/Behavioral Health manager

• Works closely with PCP's, patient care management teams, CP/SSO's and other ACO team members

• Does not supervise the work of others.

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment. Learn more ( about this requirement.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled