Community Health Worker (CHW)

MFM Health • Danvers, MA

4d • $25 - $34

About The Position

MFM Health is seeking dedicated and community-focused candidates for the Community Health Worker (CHW) position. The Community Health Worker (CHW) serves as a key member of the care team, supporting patients in navigating healthcare systems, accessing community resources, and addressing social determinants of health. This role focuses on outreach, care coordination, and removing barriers to improve patient outcomes and reduce acute care utilization.

Requirements

• Experience in community health, public health, or care coordination preferred.
• Strong knowledge of community resources and social services.
• Excellent communication and cultural competency skills.
• Ability to build trust with diverse patient populations.
• Willingness to obtain Massachusetts CHW certification within (6-12) months of hire required.
• Experience working with underserved or high-risk populations.

Responsibilities

• Conduct ED discharge follow-up calls and maintain tracking systems to identify frequent ED utilization trends, support value-based care initiatives, and improve patient/provider education and care coordination.
• Perform outreach and "tuck-in" calls for high-risk patients.
• Engage patients in longitudinal care programs.
• Complete and follow up on SDOH screenings.
• Assist patients with food security resources, housing support, and transportation services.
• Connect patients with community-based organizations.
• Assist with MassHealth and other insurance applications.
• Help patients understand benefits and coverage.
• Serve as a critical bridge between primary care and behavioral health services by helping identify appropriate behavioral health resources, supporting referral coordination, maintaining knowledge of insurance and access variables, and improving patient access while reducing fragmentation of care.
• Proactively identify and engage patients with unmet mental health or substance use needs, particularly those with frequent ED utilization, in collaboration with providers and the clinical care team.
• Strengthen patient adherence and follow-through with behavioral health care through consistent outreach and support.
• Coordinate and support a wide range of patient care needs to improve continuity, reduce gaps in care, and assist with operational follow-through on complex or unresolved tasks.
• Coordinate durable medical equipment (DME), home health/VNA services, specialty referrals, community resources, insurance-related barriers, and other patient support needs.
• Communicate closely with providers, nursing, care management, and internal departments to ensure timely follow-up and streamlined patient care coordination.
• Support value-based care and population health initiatives through identification and outreach of high-risk or high-utilizing patients.
• Assist with tracking and reporting trends related to ED utilization, barriers to care, and social determinants of health.
• Support patient engagement and enrollment in care management programs, while helping connect patients to appropriate clinical, behavioral health, and community-based resources to improve overall health outcomes and reduce fragmentation of care.
• Work closely with Nurse Manager, Care Management RN, Providers, and External partners (hospitals, rehab facilities, community orgs).
• Escalate clinical concerns, worsening symptoms, or urgent patient needs to nursing staff or providers as appropriate.

Benefits

• Discretionary paid time off
• 401(k) plan with employer match
• Profit-sharing bonus structure
• Continuous opportunities for learning and career advancement

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed