Community Health Worker - ACO

Job Description

Job Title: Community Health Worker - ACO

Job Details

Posting Date: May 7, 2025

Reference ID: 241958

Location: Methuen, Massachusetts

Work Location: Hybrid (3 days onsite, 2 days remote for patient visits or administrative tasks)

Discipline: Community Health

Job Type: Full-time

Salary Expectations/Pay Rate or Range: $19.00 - $24.00 per hour

Schedule/Shift: Monday - Friday, 8:00 AM - 4:30 PM or 8:30 AM - 5:00 PM

Job Description

Under the guidance of the Director of Population Health and in collaboration with the integrated care team, the Community Health Worker (CHW) plays a vital role in coordinating care for patients with Health-Related Social Needs (HRSN). The CHW serves as a liaison between ACO members and community-based service providers, managing a caseload of 60-70 patients and enrolling 13-15 new patients monthly.

Responsibilities/Job Duties:

HRSN Screening and Care Planning:

Assess positive HRSN screenings and develop individualized care plans.

Implement care plans, providing health education and facilitating access to services such as housing, financial assistance, food security, utilities, education, and community support.

Monitor patient progress, coordinate referrals, and adjust care plans as needed.

Complete necessary documentation, including applications for utility assistance, SNAP, disability, SSI, DTA, and housing.

Patient Engagement:

Establish trusting relationships to connect patients with primary care teams.

Implement engagement strategies for hard-to-reach patients.

Conduct home visits and accompany patients to appointments as needed.

Follow up on referrals and coordinate with outreach and enrollment for health insurance coverage.

Transition of Care:

Follow up on post-discharge referrals to mitigate risks, ensure follow-up appointments, and resume home-based services.

Communicate barriers to care to the primary care team and participate in pre-visit planning.

Engage with patients between visits through various methods.

Documentation and Meetings:

Ensure accurate documentation of all patient interactions in the Electronic Health Record (EHR).

Perform chart reviews and participate in ACO meetings.

Comply with organizational policies and participate in quality improvement efforts.

Minimum Education and Experience Qualification Requirements:

High School Diploma or equivalent (required).

Bilingual in Spanish (required).

Valid driver's license and access to a vehicle.

Knowledge of community resources and ability to assess and implement based on assessments.

Demonstrated success in working as part of a multi-disciplinary team.

6-12 months of experience working with patients with chronic medical and behavioral health needs.

Commitment to obtain Community Health Worker certification within 6 months of hire (will cover associated costs).

For California Applicants:

We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).

This position is subject to a background check based on its job duties, which may include patient care, working with vulnerable populations, access to financial and confidential information, driving, working with heavy machinery, or working in a warehouse or laboratory environment. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.Company Description

Here at Medix, we are dedicated to providing workforce solutions to clients throughout multiple industries. We have been named among the Best and Brightest Companies to Work For in the Nation for two consecutive years. Medix has also been ranked as one of the fastest growing companies by Inc. Magazine.

Our commitment to our core purpose of positively impacting 20,000 lives affects not only the way we interact with our clients and talent, but also with our co-workers! The goal is lofty, but it is made attainable through the hard work and dedication of our teams and their willingness to lock arms together. Are you ready to lock arms with us?

Full-time

Hybrid remote