Job Description

Position: Community Wellness Advocate       

Department: Center for the Urban Child and Healthy Family

Schedule: 40 hours per week

POSITION SUMMARY :

The Community Wellness Advocate (CWA) is a key member of the Pediatric Clinic team who helps promote and maintain stable health and wellness for families, through integrating and connecting hospital, home-based, and community-based services. 

CWAs are responsible for providing advocacy and case management services; developing and tracking an interdisciplinary care plan based on identified patient needs; partnering with families to establish and enact health goals; facilitating access to and coordination among social service resources and other internal and external resources; monitoring the families’ progress; and problem-solving with patients to both accelerate and enhance access to concrete supports. 

CWAs provide clinic-based, in-home or community-based one-on-one, family, and/or interdisciplinary group support and collaborate with all members of the care team to conduct needs assessments to identify and respond to barriers to the families’ health and wellness. 
As a member of an innovation team tasked with testing new and novel care delivery approaches, the specific activities of the CWA may evolve over times as the Pediatric clinic evolves.

JOB RESPONSIBILITIES:

The following are key activities expected for this role:

• Functions a key member of an inter-disciplinary team (social workers, behavioral health clinicians, physicians, resource specialists, clinical support staff, etc.)
• Provides parent coaching and support, including outreach to and engagement with families to define individual goals, promote healthy development and access to care and services
• Schedules and completes initial hospital, clinic, or community-based (homes, shelters, housing agencies, substance use treatment programs, etc.) visit screening, care plan, and follow up visits and phone calls for enrolled patients within specified timeframes
• Assists families in addressing and overcoming barriers with a range of concrete supports, including but not limited to:  healthcare support services, behavioral health, financial mobility coaching, school-based interventions, early-intervention, child-care and caregiver support, housing, support with utility bills, food, financial entitlements, clothing, transportation, food pantries, violence prevention, social isolation and any other appropriate community resources
• Teaches families key educational and developmental messages using a variety of culturally, linguistically and educationally appropriate strategies, in a variety of settings
• Clearly documents all activities in the patient’s record and care management system. Records and monitors the participants’ progress toward goals within specific timeframes.  Documents assessments and key patient updates in Epic system; documents relevant day-to-day activities and patient data.
• Communicates plans and updates with members of the care team
• Works in partnership with the SW to comprehensively assess families’ needs and strengths
• Develops and maintains strong relationships with the community and community resources to ensure patient access
• Engages in ongoing training and learning

Must adhere to all of BMC’s RESPECT behavioral standards.

Supervision Exercised

• None

Supervision Received

• Regularly scheduled meetings with Program Manager

JOB REQUIREMENTS

Education Required:

• HS Diploma with knowledge of MA community services landscape (specific knowledge of services in Dorchester and Roxbury preferred) or bachelor’s degree
• Completion of Community Health Worker training program/certification program or equivalent work experience

Experience Preferred/Desirable:

• 2 years of experience as a Community Health Worker or Community/Social Advocate is preferred
• Prior work with Medicaid population preferred
• Experience with care coordination/care management
• Experience in healthcare database/medical management system
• Prior customer service experience
• Training in motivational interviewing techniques
• Knowledge and experience in evidence-based prevention programs
• Bilingual
• Successful completion of Community Health Worker formal training/certification program or equivalent

Required Licensure, Certification or Conditions of Employment:

• Pre-employment background check

Competencies, Skills, and Attributes:

• Basic knowledge of the health care system
• Motivational interviewing skills
• Interest and experience in community health and outreach. Knowledge of community based resources and how to build linkages with them
• Ability to multi-task
• Ability to work independently as well as part of a team
• Demonstrated oral and written communication skills
• Understanding of how language, culture and socioeconomic circumstances affect health. Desire to work with diverse, multi-cultural, multi-lingual populations
• Intermediate skill level with Microsoft Office products – Outlook, Word, Excel
• Strong data entry and tracking skills

Working Conditions and Physical Effort

• Fast paced environment
• No or very limited exposure to physical risk.
• No or very limited physical effort required
• Regular and reliable attendance is an essential function of the position
• Travel within the plan geographic area required
• Work will be performed in the field as well as some home/corporate office work.

Equal Opportunity Employer/Disabled/Veterans

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