Title: Community Health Worker, Maternal Newborn Advocate (Part-Time)
Reports to: Manager of Care Management
Classification: Individual Contributor
Location: Boston (Hybrid)
Job description revision number and date: V 5.0; 1/21/2025 

Organization Summary:

Community Care Cooperative (C3) is a 501(c)(3) non-profit, Accountable Care Organization (ACO) governed by Federally Qualified Health Centers (FQHCs). Our mission is to leverage the collective strengths of FQHCs to improve the health and wellness of the people we serve. We are a fast-growing organization founded in 2016 with 9 health centers and now serving hundreds of thousands of beneficiaries who receive primary care at health centers and independent practices across Massachusetts. We are an innovative organization developing new partnerships and programs to improve the health of members and communities, and to strengthen our health center partners.

Job Summary:

As an integral member of the care management team, the Maternal Newborn Advocate Community Health Worker (CHW) is a part-time role, averaging 20 hours per week. The CHW will have the opportunity to make a profound impact on the lives of pregnant and postpartum individuals living with complex and/ or chronic conditions, many of whom also face multiple barriers accessing care and need support to succeed with achieving health care goals. This position requires flexibility and may vary from day-to-day to meet members where they are. Outreach methods may vary based on the needs of the organization and may include telephonic or in person support in a variety of potential settings such as but not limited to, the community, home, facility, or health center.

The Maternal Newborn Advocate CHW supports high-risk pregnant and post-partum members who are at-risk for an adverse delivery based on complex social, behavioral and health needs with consideration of all levels of healthcare disparity. The Maternal Newborn Advocate CHW provides ongoing management of the birthing individual and newborn for 12 months post-partum, connecting members with the appropriate services and program, while helping to promote self-management of their social needs. The advocate will work with all members of the care management team in helping members achieve their goals. This role is hybrid with travel to FQHCs required.

Responsibilities:

• Works under the guidance of the Licensed Care Manager or Program Leaders (Leads, Supervisor, Manager or Director)
• Conducts initial outreach calls to encourage member/representative and caregivers to participate in care management programs
• Develop and implement outreach plans in collaboration with team colleagues, based on individual, family, and community needs, strengths, and resources
• Identify and share appropriate information, referrals, and other resources to help individuals, families, groups and the primary care team meet their needs
• Gather and combine information from different sources to better understand clients, their families and communities
• Initiate and sustain trusting relationships with individuals, families, social networks and primary care team
• Use a range of outreach methods to engage individuals and groups in diverse settings
• Share community assessment results with colleagues and community partners to inform planning and health improvement efforts
• Use effective communication skills
• Act as a cultural mediator by educating and supporting providers in working with clients from diverse cultures and help clients and community members interact effectively with professionals to promote health, improve services, and reduce health care disparities
• Addresses language and cultural barriers to care
• Coaches and guides member/representative to meet both personal and clinical goals
• Assists in scheduling appointments on behalf of member/representative
• Work with individuals, family, community members, primary Care Managers (CM), and primary care team to address issues that may limit opportunities for healthy This includes completing Social Drivers of Health (SDOH) screening and other tactics to obtain support for barriers to care
• Provide care coordination, which may include but not limited to facilitating care transitions, supporting the completion of referrals, and providing or confirming appropriate follow-up
• Help bridge cultural, linguistic, knowledge and literacy differences among individuals, families, communities, and providers
• Helps member/representative access community and government-based service agencies including completing paperwork for the member
• Helps teach the member/representative and/or care giver about symptom response plans
• Participates in the integrated care team meetings and rounds as required
• Complies with reporting, record keeping, and documentation requirements in one’s work
• Use appropriate technology, such as computers, for work-based communication according to C3 and health center requirements
• Creates and maintains a comprehensive inventory of local community resources, improving accessibility for patients and providers, and linking patients with the appropriate support services
• Establishes relationships with community agencies, resources and supports that are relevant to a Medicaid Population
• Assist with Medicaid applications, food, and nutrition benefits, housing applications, coordinating transportation,
• Travel throughout assigned area and engage members at their homes/ hospitals/community-based locations and or accompany members to appointments as appropriate
• As needed, cover other areas in person or via telephonic support
• Other duties as assigned

Required Skills:

• Experience within the ACOs member population preferred including Medicare/Medicaid
• Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Providers, Nurses, Social Workers, and other health care teams
• Bi/multi-lingual preferred or experience with Language Translation Services
• Experience working with patients with chronic medical and behavioral health needs
• Must be flexible and adaptable to change
• Demonstrate the ability to work independently
• Must demonstrate excellent interpersonal communication skills
• Additional desirable qualities include enthusiasm and passion for helping patients, genuine spirit, kind, and empathetic nature, and one who embraces a ‘go with the flow’ mentality
• Experience using appropriate technology, such as computers, for work-based communication, according to organizational requirements
• Experience and proficiency with Microsoft Office and online record keeping

Desired Other Skills:

• Experience working with Maternal/Newborn and/or Post-Partum population preferred
• Familiarity with the MassHealth ACO program
• Familiarity with Federally Qualified Health Centers
• Experience with anti-racism activities, and/or lived experience with racism is highly preferred

Qualifications:

• Minimum 2-5yr experience as a Community Health Worker (CHW), Maternal Newborn Advocate, Medical Assistant (MA), Engagement Specialist, Certified Doula
• A valid driver's license and provision of a working vehicle

** In compliance with Covid-19 Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law. **