Community Health Advocate | Care Coordination & Resources

Umass-Memorial-Health-; Milford (MA); On-site; USD 38,000 - 69,000; Full time

Job summary

UMass Memorial Health is seeking a Community Health Worker to collaborate with the care team, advocate for high-risk patients, and help them navigate health and community resources. The CHW may handle a caseload independently or with RN/SW support and assist with state program applications.

The role emphasizes culturally sensitive education, care coordination, and linkage to medical and behavioral health services, with emphasis on documentation and timely follow-ups.

Qualifications

• 1–2 years of experience with patients managing complex medical and behavioral health issues.
• Experience navigating behavioral health systems.
• Strong communication, organizational, and time management skills.
• Ability to work independently and collaboratively.
• Competence in virtual platforms and EMR systems.

Responsibilities

• Collaborate with care team to manage caseloads and build capacity.
• Support patients in self-advocacy and community engagement.
• Map and share community resources like housing, food, and shelter.
• Connect families with services and track referrals.
• Assist with applications for MassHealth, DTA, DDS, DMH and other programs.
• Coordinate services for children with autism and behavioral health needs.
• Locate mental health providers and ensure referrals.
• Attend education and mental health meetings with families.
• Provide peer support and cultural mediation.
• Deliver culturally appropriate health education.
• Conduct follow-up calls, virtual visits, and home visits as needed.
• Help patients organize records and calendar follow-ups.
• Document encounters in the EMR per MRPG/MGB workflows.

Skills

Communication

Organizational skills

Time management

Independent & collaborative work

Virtual platforms proficiency

Education

Associate degree or equivalent experience

BSW or BEd preferred

Relevant community experience

Tools

EMR systems

Virtual visits platforms

Job description

UMass Memorial Health is seeking a Community Health Worker to collaborate with the care team, advocate for high-risk patients, and help them navigate health and community resources. The CHW may handle a caseload independently or with RN/SW support and assist with state program applications.

The role emphasizes culturally sensitive education, care coordination, and linkage to medical and behavioral health services, with emphasis on documentation and timely follow-ups.