Community Health Worker: Care Coordinator & Engagement

Greater Lawrence Family Health Center, Inc.; Methuen (MA); On-site; USD 42,000 - 60,000; Full time

Job summary

Greater Lawrence Family Health Center, Inc. in Methuen, MA seeks an ICT Community Health Worker to support care coordination, HRSN assessment, and patient engagement across the care continuum.

You will collaborate with the Integrated Care Team to develop and monitor care plans, connect patients to housing, food, and community supports, and guide transitions of care while maintaining documentation in the EHR.

Qualifications

• CHW Certification required with commitment to obtain certification within 6 months of hire.
• CPR Certification required.
• Bilingual English/Spanish speaking preferred.
• Knowledge of community resources and ability to assess and implement based on assessment.
• Strong problem solving and critical thinking; escalation as needed.
• Experience in a multi-disciplinary team.
• Experience with patients with chronic medical and behavioral health needs.
• Experience with diverse populations and workforce.
• Flexible and adaptable to change.
• Strong organizational skills and ability to multitask and work independently.
• Ability to work independently while collaborating as needed.
• Excellent interpersonal communication and written skills.
• Desire to help patients in a non-judgmental and empathetic way.
• Cultural competence with diverse populations; valid driver's license and transportation.
• Proficiency with telehealth technologies and travel to patient homes.

Responsibilities

• Screen positive patients and formulate care plans addressing goals.
• Provide health education and assist with housing, finances, food, utilities, education, and community supports.
• Monitor progress and coordinate referrals per plan of care.
• Communicate patient updates to ICT team and adjust plans as needed.
• Complete necessary documentation (utility assistance, SNAP, disability, housing).
• Establish trusting relationships and engage hard-to-reach patients.
• Conduct home visits and accompany patients to appointments to ensure adherence.
• Follow up on referrals and warm handoffs for additional care coordination.
• Support transitions of care post-discharge and post-visit planning.
• Participate in ICT meetings and quality improvement efforts.
• Educate patients on using telehealth tools and devices.

Skills

Bilingual English/Spanish

CPR Certified

Community Health Worker Certification

Microsoft Office

Interpersonal communication

Problem solving

Organizational skills

Education

Community Health Worker Certification

CPR Certification

Tools

Microsoft Office (Word, Excel, PowerPoint)

Job description

Greater Lawrence Family Health Center, Inc. in Methuen, MA seeks an ICT Community Health Worker to support care coordination, HRSN assessment, and patient engagement across the care continuum.

You will collaborate with the Integrated Care Team to develop and monitor care plans, connect patients to housing, food, and community supports, and guide transitions of care while maintaining documentation in the EHR.