High-Acuity Community Health Worker

Fenway Health provides comprehensive care for a significant number of people living with HIV. Some patients face multiple social barriers that make it challenging for them to engage in their healthcare and maintain viral suppression, which leads to negative health outcomes for the patient and increases the risk of infection transmission to others.  

The High Acuity Community Health Worker Program at Fenway Health is funded by MA DPH and BPHC/HRSA to provide medical case management services to people living with HIV/AIDS (PLWHA) who are not virally suppressed or at risk of falling out of care. Under the general supervision of the Care Coordination Nurse Manager and High Acuity Social Worker, the High Acuity Community Health Worker provides low barrier case management, health navigation services, and coordinates referrals to community resources to people living with PLWHA who require enhanced care to maintain viral suppression, engagement in care, and successfully manage social determinants of health. 

Representative Duties:

• Provides case management services to PLWHA patients with high level of need in order to help them achieve and maintain viral suppression  
• Provides services to patients who have challenges engaging in medical care, uncontrolled HIV viral load, or who otherwise are identified as high risk using a harm reduction framework 
• Forms productive, empathic working relationships with assigned patients on their caseload and with folks who attend drop in services 
• Screens eligibility and reviews medical, mental health and social history of patients in need of intensive case management services, identifies needs, and refers patients as appropriate in a timely, courteous manner. Referrals may include need for further assessment/evaluation by licensed clinicians or review by a supervisor. 
• Provides high level of support to ensure barriers to poor medical and medication compliance are mitigated 
• Provides information to patients about available community resources and assists patients to determine eligibility and obtain services 
• Provides on-going support to patients as appropriate and conducts outreach to help retain patients in care or to encourage patients to utilize additional necessary services 
• Links medical patients to mental health and substance use services as appropriate 
• Interacts with patients in community settings (home visits, community locations, hospitals, other program sites) 
• Adheres to timely and thorough chart documentation standards 
• Meets established service delivery targets 
• Adheres to NASW Code of Ethics 

Collaborates with internal stakeholders and other agencies:

• Develops and maintains resource listings appropriate for Fenway Health patients 
• Participates in community councils, boards and groups as appropriate to further departmental objectives  
• Works with Medicaid, Medicare, Welfare, Social Security, housing, educational, day care and other institutions to assist clients 
• Consults with a variety of health center and community staff (Nutritionists, Home Health Aides, Nurses, Behavioral Health staff and Medical staff) about specific clients and general approaches to patient treatment 

Performs and completes administrative tasks in a timely and efficient manner:

• Completes psychosocial assessments and care plans for newly enrolled patients 
• Writes case notes for each patient interaction 
• Collects necessary programmatic documentation and maintain up-to-date patient files and charts 
• Assists patients with applications for enrollment in entitlement programs 
• Assists medical teams with case management administrative tasks 
• Participates in staff and team meetings and conferences 
• Participates in professional activities to maintain professional standing 
• Participates in program reporting and accountability as required by funding agencies 

Meets agency participatory expectations:

• Suggests and participates in continuing quality improvement efforts  
• Adheres to all agency and departmental policies and procedures 
• Participates in quality assessment and improvement activities as requested 
• Adheres to the highest principles of patient and client confidentiality 
• Adheres to established safety policies, procedures and precautions; identifies potential or actual unsafe situations in the environment and takes measures to rectify the situation 
• Attends all required meetings, in-services and professional trainings 
• Attends all regularly scheduled research meetings, trainings, forums and pertinent FCH staff meetings 
• Maintains professional competence necessary to perform job responsibilities; maintains and provides agency with records of continuing education activities 
• Serves on agency committees and in professional organizations when requested 

Performs related duties as required

Requirements

• Bachelor’s Degree in the following: LADC, social work, public health, psychology, mental health counselling or a similar field. Relevant experience in the area of social work, harm reduction, or housing support may be substituted for educational requirement 
• Two years case management experience in a medical or community setting 
• Experience delivering services in using a harm reduction, low barrier framework 
• Flexibility, adaptability, independence, and ability to multitask  
• Ability to work harmoniously and effectively with colleagues, patients, clients and vendors across the spectrum of diversity, including but not limited to race, ethnicity, color, gender identity, sexual orientation, age, socio-economic status, national origin and immigrant status, religious or spiritual identity, disability (physical, mental, emotional and developmental), veteran status, and/or limited English proficiency. 
• Willingness to contribute towards Fenway’s efforts in becoming an anti-racist organization and promoting a culture dedicated to ongoing development in service of humility, equity, diversity, inclusion, and belonging, where differences are acknowledged and valued. 

Preferred Qualifications:

• Experience with LGBTQIA+ population  
• Experience working with people living with HIV 
• Spanish speaking strongly preferred 
• Excellent interpersonal skills and ability to be an effective team member 
• Experience working with an ethnically, culturally and racially diverse work staff preferred 

Physical Requirements:

Ability to meet the following physical requirements with or without reasonable accommodations: 

• Sit at a computer station for extended periods of time 
• Ability to keyboard for extended periods of time 
• Ability to make community visits, travel regularly, and work in non-office settings 

We offer competitive salaries, and for those who qualify, an excellent benefits package; including comprehensive medical and dental insurance plans, generous paid time off, commuter benefits, and more.

LGBTQIA+ identified persons, Black, Indigenous, and other people of color (BIPOC), and individuals from other historically underrepresented communities are strongly encouraged to apply.

This is a union position in a Fenway Health bargaining unit represented by 1199 SEIU United Healthcare Workers East.