The Community Health Worker (CHW) will support the implementation of the CHW Pilot designed to address health disparities, improve outcomes, and reduce avoidable utilization among Medicaid members with Type 2 diabetes. This role is critical in addressing identified needs, including high diabetes prevalence and significant social determinants of health (SDoH) risk within targeted counties.

Responsibilities

• Conduct telephonic, virtual, and face-to-face outreach and engagement with assigned members.
• Maintain an active caseload (approximately up to 30 members), with engagement duration based on member needs.
• Complete required screenings and assessments, including initial engagement and health equity screeners within required timeframes.
• Develop and implement individualized action plans in collaboration with members and interdisciplinary care teams.
• Provide education and support related to Type 2 diabetes management, including medication adherence, nutrition, physical activity, and lifestyle behaviors.
• Identify and address gaps in care, supporting members in completing recommended preventive and follow-up services.
• Connect members to community-based resources addressing SDoH needs (e.g., food, housing, transportation) and ensure closed-loop referral follow-up.
• Assist members in navigating healthcare services, including scheduling and attending primary and specialty care appointments.
• Participate in interdisciplinary team meetings and case rounds to support care coordination.
• Document all member interactions, outreach attempts, and interventions in designated systems in accordance with program requirements.
• Support member engagement in pilot initiatives and services, including education programs, community events, and resource utilization.
• Promote positive member relationships and culturally competent care aligned with community needs.

Required Qualifications

• Experience working in community health, social services, care management, or related field.
• Experience engaging with underserved or high-risk populations.
• Strong communication, interpersonal, and engagement skills.
• Ability to build trust and maintain relationships with diverse populations.
• Knowledge of community resources and SDoH-related services.
• Ability to manage a caseload and document activities accurately.
• Must live in Middlesex County or nearby

Benefits This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

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