Community Health Worker

Vinfen Hyannis , MA 02601

Posted 1 month ago

The Community Health Worker (CHW) will provide care coordination and care management for MassHealth Members who are enrolled in an Accountable Care Organization (ACO) or Managed Care Organization (MCO) plan. The CHW works in collaboration with the Community Partner Care team and the clinical staff of each Enrollee's ACO/MCO's plan to minimize duplicative efforts, promote integrated care, and to ensure quality and continuity of care. The CHW is at the helm of organizing and coordinating resources and services in response to the Enrollee's healthcare needs across multiple settings. This role drives outreach and engagement, assessment and care planning, care transitions well as health and wellness coaching.

Job Duties and Responsibilities:

The essential job duties/responsibilities of the position include but are not limited to the information listed below:

  • Outreach to and engage Enrollees of an ACO plan as referred to CP Program.

  • Coordinate the completion of the Comprehensive Assessment (CA).

  • Conduct initial and ongoing risk assessment; design personal crisis management plans, relapse prevention and harm reduction strategies with members who have been identified as behaviorally complex in collaboration with team LPHAs.

  • Coordinate the development, implementation, and ongoing review of the Person Centered Treatment Plan (PCTP) inclusive of any LTSS and / or SDH needs or goals of the Enrollee.

  • Drive referrals regarding connections to any community or social services that align with the Enrollees needs and goals.

  • Submit CA, PCTP, and all PCTP updates in accordance with the data sharing agreement CP and ACO/MCO Plan.

  • Collaborate closely with PCP and other providers, including but not limited to community resources, to assure appropriate referrals based on level of care needed to optimize outcomes and minimize risk.

  • Communicate and collaborate with ACO/MCO teams and serve as a team resource.

  • Collaborate with ACO Plan, PCP, and other health care providers regarding changes in services, care transitions, and crisis intervention while focusing on continuity and quality of client care and potential efficiencies and cost-savings.

  • Obtain required Prior Authorization from ACO/MCO Plan for relevant/necessary services.

  • Manage all care transitions through collaboration with Enrollee, community provider staff, ICT, and hospital staff to ensure a safe discharge plan and a well-coordinated implementation of that plan.

  • Ensure for medication review and reconciliation as triggered by a care transition or by a medication change through an outpatient medical or psychiatric visit.

  • Perform other related duties, as required.

Why Vinfen? We are committed to you! We offer great training, great benefits, career growth and job security!

Our comprehensive and generous benefits package includes:

  • A fully funded, employer-sponsored retirement plan that requires no employee contribution as well as an employee-funded 403(b) plan

  • First-rate Medical, Dental and Vision plans that are open all employees scheduled to work 30 hours per week or more. Plus, we offer a generous employer contribution toward the cost of medical insurance!

  • Employer-paid Life, Accidental Death & Dismemberment and Long-Term Disability Insurance (no cost to you!)

  • Employer-paid Short-Term Disability Insurance along with the option to purchase additional, voluntary, Short-Term disability insurance

  • Flexible Spending Reimbursement Accounts (Health and Dependent care)

  • Voluntary Term, Whole Life, Accident and Critical Care Insurance

  • Generous paid time off (Employees scheduled to work 20 hours or more per week):

  • 15 days of Vacation per year

  • 11 Paid Holidays

  • 10 Sick Days per year

  • 3 Personal Days per year

  • Educational Assistance and Remission Programs

  • $500 Employee Referral Bonus with no annual cap!

  • Other generous benefits including discounted YMCA memberships, access to discounted movie tickets and more!

Founded in 1977, for 40 years Vinfen has been a leading nonprofit human services organization that "transforms lives" by building the capacity of individuals, families, organizations and communities to learn, thrive and achieve their goals. Vinfen supports thousands of adolescents and adults with psychiatric, developmental and behavioral disabilities at more than 200 sites with 2,800 employees in eastern Massachusetts and Connecticut. www.vinfen.org/careers

My Vinfen. My Community. My Job.

Vinfen is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, pregnancy, sexual orientation, gender identity, national origin, age, protected veteran status, or disability status.

  • Bachelor's degree in Human Services field strongly preferred

  • A minimum of 3 years of case management experience preferred, experience working with people living Serious Mental Illness and/or Substance Abuse Disorder strongly preferred

  • Strong organizational and collaboration skills

  • Ability to prioritize work tasks and work both independently and as part of a multi-disciplinary team

  • Ability to effectively represent the organization in a variety of circumstances and forums

Driving is a requirement for this position. You must have access to a fully insured,


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Community Health Worker

Vinfen