Community Health Worker TMIN Central/Northern Region

Tufts Medicine Integrated Network - Burlington, MA

Full-time - Entry Level

Hybrid - Burlington, MA

About the position

The Community Health Worker position at Tufts Medicine Integrated Network is designed to provide culturally-competent services to patients, assisting them in navigating community services and adopting healthy behaviors. This role involves care coordination, patient education, and facilitating communication among healthcare providers, particularly focusing on pediatric patients and their families in the Central and Northern regions of Massachusetts.

Responsibilities

• Promotes, maintains, and improves the health of patients and their families through disease education and wellness advocacy.
• Meets patients in their homes to perform structured assessments, including goal setting and motivation to meet health goals.
• Establishes trusting relationships with patients and their families, providing support and informal counseling using motivational interviewing.
• Assists patients with completing applications and registration forms for financial and community-based resources.
• Refers patients to internal or external care management services when other issues are identified.
• Provides ongoing follow-up with patients via phone calls, home visits, and visits to other settings.
• Works closely with medical providers to ensure comprehensive and coordinated care for patients.
• Communicates consistently with hospital care coordinators to update and evaluate patient/family status.
• Reports high-risk problems such as homelessness and substance abuse after assessment by a licensed social worker clinician.
• Acts as a patient advocate and liaison between patients/families and community service agencies.
• Manages an assigned caseload of patients and records patient information in the designated EMR within 48 hours after contact.
• Maintains collaborative relationships with peers and colleagues to achieve organizational goals.
• Acts as a liaison between internal and external providers and community resources.

Requirements

• High school diploma or equivalent.
• One year of experience in a healthcare-related field such as hospital, home health provider, or community-based agency.
• Valid, state-issued driver's license and reliable transportation.

Nice-to-haves

• Associate's degree in Public Health, Healthcare, or other health science.
• Three years of experience in a healthcare-related field.
• Bilingual.
• Experience working in a multi-cultural setting.
• Experience working in a community-based setting.