Community Health Worker - C3 ACO

Part Time: 20 Hours

Established in 1980, the Greater Lawrence Family Health Center (GLFHC) is a multi-site mission-driven non-profit organization employing over 700 staff whose primary focus is providing the highest quality patient care to residents throughout the Merrimack Valley. Nationally recognized as a leader in community medicine (family practice, pediatrics, internal medicine, and geriatrics), GLFHC has clinical sites throughout the service area and is the sponsoring organization for the Lawrence Family Medicine Residency program.

GLFHC is currently seeking a Community Health Worker (CHW) to join our care management team. The Community Health Worker will have the opportunity to make a profound impact on the lives of people living with complex and/ or chronic conditions, many of whom also face multiple barriers accessing care and need support to succeed with achieving health care goals. This hybrid position requires flexibility and may vary from day-to-day to meet members where they are. Outreach methods may vary based on the needs of the organization and may include telephonic or in person in a variety of potential settings such as but not limited to, the community, home, facility, or health center.

• Conducts initial outreach calls to encourage member/representative and caregivers to participate in care management programs
• Develop and implement outreach plans in collaboration with team colleagues, based on individual, family, and community needs, strengths and resources
• Identify and share appropriate information, referrals, and other resources to help individuals, families, groups and the primary care team meet their needs
• Act as a cultural mediator by educating and supporting providers in working with clients from diverse cultures and help clients and community members interact effectively with professionals to promote health, improve services, and reduce health care disparities.
• Work with individuals, family, community members, primary CM and primary care team to address issues that may limit opportunities for healthy behavior. This includes completing Social Drivers of Health (SDOH) screen and other tactics to obtain barriers to care.
• Coaches and guides patients to meet both personal and clinical goals
• Provide care coordination, which may include but not limited to facilitating care transitions, supporting the completion of referrals, and providing or confirming appropriate follow-up
• Help bridge cultural, linguistic, knowledge and literacy differences among individuals, families, communities, and providers.
• Helps member/representative access community and government-based service agencies including completing paperwork for the member.

• Bi-lingual Spanish speaking required
• Demonstrated success in working as part of a multi-disciplinary team
• Experience working with patients with chronic medical and behavioral health needs
• Must be flexible and adaptable to change
• Strong organizational skills with ability to prioritize and multi-task as needed
• Must demonstrate excellent interpersonal communication skills