Job Description

Overview A Community Wellness Advocate (CWA) is a trusted member of the community who helps high risk patients maintain stable health and wellness along a continuum, through integrating and connecting hospital, home-based, and community-based services. CWAs are responsible for providing advocacy and case management services; developing an interdisciplinary care plan based on identified patient needs; facilitating access to social service resources and other internal and external resources; monitoring the patient’s progress; and problem-solving with patients to both accelerate and enhance access to concrete supports. CWAs provide in-home or community-based one-on-one, family, and/or interdisciplinary group support to high risk care patients and collaborates with the Nurse Care Manager, PCP, and other members of the care team to conduct needs assessments to identify and respond to barriers to the patient’s health and wellness. Position Position: Community Wellness Advocate Department: Pop Health - Care Management Schedule: Full Time Location and hours: This position is Monday-Friday business hours, 8:30am-4:30pm. No weekends or major holidays. This position is located in SouthCoast, MA, serving the Fall River, New Bedford, Dartmouth, Westport, Wareham, and Taunton communities. The Community Wellness Advocate (CWA) must possess a valid driver’s license and have vehicle transportation. Business casual dress attire. This is a hybrid position, requiring both in person and telephonic work. The CWA has flexibility to work from home 1-2 days per week and will also conduct face-to-face patient visits in the home, community, and hospital settings. The CWA will be required to work from the designated practice site 1-2 days per week onsite. Important note: This role does not provide hands-on care or services typically noted as home health care. Essential Responsibilities / Duties Initiates face to face contact with eligible patients to describe role, explain participation benefits and begin screening process. Schedules and completes initial hospital, clinic, or community-based visits and follow-up visits and phone calls for patients within specified timeframes. Teaches key educational messages using culturally, linguistically and educationally appropriate strategies in a variety of settings. Documents all activities in the patient’s record and care management system. Participates with other staff in community outreach, presentations to community organizations, development of materials, and outreach activities. Works with patients and providers to set goals for patient care and provides guidance to achieve those goals. Reinforces educational messages regarding disease self-management by linking clients with supportive community services and programs. Presents patients at case review meetings succinctly and logically. Consults with Nurse Care Manager, primary clinical staff, behavioral health teams and/or PCP regarding complex patient situations and incorporates provider feedback to optimize the care plan. Demonstrates ability to function within an interdisciplinary team and connect the patient with resources as needed. Records and monitors participants’ progress toward goals within specified timeframes. Documents assessments and key patient updates in Epic; records day-to-day activities and patient data. Prepares reports and documents as needed or requested. Assists patients with organizing records, making follow-up appointments, attending follow-up appointments, and filling prescriptions. Helps patients fill out applications for Medical Assistance, Housing, and SNAP. Provides advocacy, patient education and successful warm hand-offs in accessing community-based and hospital-based programs. Addresses barriers with concrete supports, including healthcare, behavioral health, financial assistance, housing, utilities, food, transportation, and other community resources. Coordinates with community-based long-term services and supports. Provides intensive home and community-based outreach, motivational interviewing and goal setting, resource connection and accompaniment to medical appointments as needed to help patients utilize healthcare effectively. CWAs may visit patients in hospital and ER settings to assist with transitions of care. Establishes culturally appropriate and trusting relationships with patients and their families. Participates in training activities as designated by the Community Wellness Manager (CWM) and attends regularly scheduled supervision and program meetings. Develops and maintains strong relationships with the community and community resources to ensure patient access. Note: The CWA will not provide hands-on care or other services noted as home health care, including but not limited to: performance assessments, provision of care, treatment, or counseling; and/or monitoring of patient health status. Education HS Diploma with community experiences or Bachelor’s degree Certificates, Licenses, Registrations Required Driver’s license required Experience Minimum of 2 years prior healthcare, public health, or community-based experience in a community setting. Knowledge And Skills Basic knowledge of healthcare system. Outstanding interpersonal skills essential for interaction with families and patients. Interest in community health and outreach. Excellent organizational skills; ability to multi-task and work independently and as part of a team. Demonstrated oral and written English communication skills. Fluency in Portuguese or Spanish preferred. Understanding of how language, culture and socioeconomic circumstances affect health. Desire to work with diverse, multi-cultural and multi-lingual populations. Proficiency with Microsoft Office applications and data entry and tracking. Equal Opportunity Employer/Disabled/Veterans According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website and applications are received only through our website. We do not ask or require downloads of any applications, or “apps” job offers are not extended over text messages or social media platforms. We do not ask individuals to purchase equipment for or prior to employment. Senioriry level Entry level Employment type Full-time Job function Sales and Business Development Industries Hospitals and Health Care #J-18808-Ljbffr Boston Medical Center (BMC)

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