Community Health Outreach Specialist - -Bonus $3,000
Bonus: $3,000, $1,500 at 3 months, $1,500 at 6 months
The Community Health Outreach Specialist (CHOS) provides expertise in engagement coordination and outreach strategies for the purpose of initiating complex care management for MassHealth Members with medical and behavioral health needs. The CHOS collaborates with the Community Partner team and ACO/MCOs (key contacts) to minimize duplicative efforts and promote integrated care. The CHOS is at the helm of planning engagement, retention of care coordination services and developing relationships with existing providers as a way to improve access to Community Partner services for eligible MassHealth members. The CHOS also contributes to interdisciplinary team meetings by organizing and coordinating resources and services in response to the healthcare needs of CP Enrollees across multiple settings. This role drives outreach and engagement, partnership development and referral recruitment. The overall goal is improve the quality of care which leads to cost-savings and improve health outcomes and experiences for Masshealth Members. This is a non-exempt position.
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 referred to CP Program.
- Support team by focusing on “hard to reach” individuals.
- Develop outreach tool kit and support systems that improve engagement outcomes across all teams.
- Coordinate and plan coordination and co location of CP services with both internal and external partners.
- Drive and obtain referrals regarding connections to community or social service partners that align with the needs and goals of target population (SDoH).
- Work with PCP offices, specialty providers and acute care settings to generate new referrals for CP teams.
- Coordinate and co locate within both internal and external programs that are working with target population.
- Communicate and collaborate with ACO/MCO teams and serve as a team resource.
- Manage a modified caseload which includes the development and completion of Comprehensive Assessments, risk assessments and complex care planning.
- Lead care transitions for “hard to reach” enrollees 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.
- Perform other duties, as required.
Knowledge and Skills:
- Strong commitment to the right and ability of people served to live, work, have meaningful relationships and receive the resources and supports needed in their community of choice
- Knowledge of person-centered, strengths-based, recovery-oriented values and principles and modalities
- Knowledge of clinical and psychiatric rehabilitation values, principles, and techniques
- Knowledge of health risks of prevalence with adults with SMI/SUD
- Knowledge of health promotion and clinical care coordination techniques
- Knowledge of motivational interviewing, stage of change and harm reduction techniques
- Knowledge of trauma-informed and culturally responsive services
- Sensitivity to the cultural, religious, ethnic, disability, and gender issues
- Skills and competence to establish supportive trusting relationships with Enrollees
- Knowledge of human, legal, civil rights, community, and other resources
- Knowledge of empowerment and self-advocacy techniques
- Knowledge of available community health, mental health and SUD services and resources
- Ability to triage/balance competing priorities
- Ability to make independent judgments and decisions
- Ability to work in a professional and confidential capacity
- Ability to work independently and as member of a multidisciplinary team
- Minimum of 3 years care management experienced preferred. Experience working with people living with SMI and/or SUD. Preference given to bi-lingual/bi-cultural applicants and those with lived experience of psychiatric conditions. In some cases, experience may be substituted for academic training.
- A COVID-19 vaccination is a requirement of the position. One COVID-19 shot is acceptable, contingent on the individual receiving the second shot within the allotted time frame.
Education and Required Credentials/Licenses:
High School diplomas or equivalent is required. BA/BS in human-services related field preferred. Certified Community Health Worker (CHW) preferred.
Driving is a requirement for this position using a personal vehicle. You must possess and maintain adequate insurance as well as maintain a safe driving record which is subject to annual checks. A valid driver's license must be presented at the time of employment. Incumbents must be at least 21 years of age, have maintained a valid US driver's license for at least one year, and must be able to pass a driver's screening background check.
- Boston, MA, USA