The MGB "Community Care Van Program" is a new, innovative mobile health program dedicated to increasing access to quality healthcare for historically marginalized communities in the greater Boston area. The Community Health Worker (CHW) is an integral member of a mobile health team that provides health services including screening and treatment for hypertension, diabetes and substance use disorder.

The mobile CHW helps patients' access and coordinate their health care; they have the skills to help patients address social/medical problems that lead to poor health. The CHW will work to create a trusting relationship with patients and help them address social determinant of health needs (such as food, housing, transportation) by connecting them to resources. The CHW will work to engage patients on adhering to key components of their health care. He/she may schedule follow-up phone calls/visits to ensure progress and will also communicate with the provider team when needed.

The community health worker will engage patients and their families in setting their own short-term goals and will track the benchmarks toward the achievement of these goals. The CHW will aid patients in the coordination and completion of appointments inside and outside of the primary care practice. In addition, the community health worker will work with patients to help decrease barriers to timely follow-up care. While the CHW is not a clinical position, it requires knowledge of basic clinical concepts and an understanding of when a referral to a licensed clinician is appropriate.

The CHW reports directly to the Operations Manager of the mobile team, and also has a reporting line to a Behavioral Health or CHW/Social Services manager for clinical guidance and supervision.

This is a hybrid role and she/he will be required to work both in-person and remotely. Some mobile clinics are scheduled during the evening and on weekends to provide greater access for community members who work during the day.

* Assists mobile team with set-up and take-down of the mobile clinic site.

* Administers screening surveys to determine patient SDOH needs.

* Assists with patient registration when needed.

* Provides culturally sensitive services to patients from different cultures.

* Supports community resource finding related to SDOH needs, including food, housing, transportation, and other areas as needed.

* Works with patients to identify and address barriers to care.

* Works with patients and providers to set goals for patient's care and motivates patients to meet their health goals.

* Connects with patients by phone to follow up on key aspects of care and to assess barriers to compliance.

* Helps address any logistic barriers, scheduling complications, childcare needs, etc., that would prevent a patient from showing up at their appointment.

* Assists patients in accessing records, making follow-up appointments and filling prescriptions.

* Helps patients develop their own plans for getting to various appointments for screening and diagnostic tests, and treatment services.

* Documents each patient encounter in detail. Tracks benchmarks of progress including short term goal completion along the way.

* Maintains regular communication with the patient's providers through clinical messages in the electronic health record, emails, phone calls and case review meetings.

* Helps patients fill out applications for state and federally funded programs such as Medical Assistance and SNAP (Supplemental Nutrition Assistance Program).

* Helps patients with questions related to health insurance and refers to financial counseling as appropriate

* Develops and maintain a strong working relationship with the schedulers of screening appointments.

* Work with medical interpreters to reach patients of other languages.

* Attends initial and continuing education training programs including self-directed reading and in-person plus online learning.

* Completes other duties as designated by Operations Manager

The community health worker position requires the ability to be self-directing, outgoing, professional, and organized. The CHW must be able to work as a patient advocate with people from many different cultures and backgrounds.

* Demonstrated commitment to impacting the care of high-risk patients.

* Ability to work both independently and as a team member in multicultural settings.

* Excellent communication skills.

* Ability to be flexible and adept to last minute changes as it pertains to scheduling, workflow, and other operational logistics.

* Strong time management, organizational and planning skills.

* Detail-oriented with the ability to multi-task.

* Sound judgment and problem-solving ability along with strong critical thinking skills.

* Ability to document all patient communications and clinical treatments accurately.

* Comply with established risk management and safety procedures as well as all local, state and federal privacy and confidentiality rules and regulations.

* Bilingual candidate in Spanish strongly preferred.

Certification is preferred

H.S. Diploma required; relevant experience in the community or Associates Degree required; Bachelor's Degree preferred.

Minimum two years of working experience; previous work in community settings preferred.

Experience working as a patient navigator/community health worker preferred.

This position entails a significant amount of time in a mobile/community environment. While much of the work may take place on the mobile clinic (van) there are duties performed outside and adjacent to the mobile clinic. It will be necessary to dress for varying weather conditions as needed. The position requires the ability to commute to and from site locations and also work remotely as required.