Community Health Worker, BH TOC

career locationBoston, MA

career datePosted February 6, 2023

career description Download PDF

Program/s: Community Care Cooperative

Reports to: Manager, Behavioral Health Transitions of Care Program

Classification: Individual Contributor

Job description revision number: v3

The Community Health Worker (CHW), Transitions of Care Program, will be a member of a team of social workers, physicians, pharmacists, community health workers, and program coordinators. The CHW will have the opportunity to make a profound impact on the lives of people living with complex and/or chronic mental health conditions, many of whom also face multiple barriers to accessing care and adhering to a provider’s treatment plan. The CHW works as an extension of the clinical care team. They will connect with patients in person, on the phone, in the hospital, and in the provider’s office. The CHW must be prepared to work from home office, hospital, Health Center, provider’s office setting, within patient’s homes, or in the community.  


  • Works under the guidance of the BH TOC Social Work Care Manager 
  • Conducts initial outreach calls to encourage patients and caregivers to participate in care management programs 
  • Engages with patients who need assistance with psychiatric and/or substance use recovery care needs 
  • Addresses language and cultural barriers to care 
  • Coaches and guides the patient to meet psychiatric and other clinical goals 
  • Helps teach the patient and/or care giver about psychiatric and/or substance misuse symptoms response plans 
  • Assists in scheduling appointments on behalf of patients and reminds patients of their upcoming visits 
  • Accompanies patients to their visits as needed 
  • Completes Social Determinants of Health Assessments 
  • Helps patients access community and government-based service agencies including filling out paperwork for the patient 
  • Arranges transportation as needed (PT1) 
  • Establishes relationships with community agencies, resources, and supports that are relevant to the Medicaid population 
  • Assists with Medicaid applications, food and nutrition benefits, housing applications, coordinating transportation, etc. 
  • Travels to engage members at their homes or in the community 
  • Participates in the integrated care team meetings and rounds as required 
  • Maintains accurate, timely documentation in electronic systems 
  • Provides team support as needed 

Required Skills: 

  • Demonstrated success in working as part of a multi-disciplinary team including communicating and working with providers, nurses, and social workers
  • Experience working with patients with chronic and mental health and/or substance misuse needs
  • Must be flexible and adaptable to change
  • Ability to work independently
  • Excellent interpersonal communication skills
  • Additional qualities that would be a good fit for our team include enthusiasm and passion for helping patients, genuine spirit, kind and empathetic nature
  • Experience working with Electronic Medical Records and health care systems
  • Experience and proficiency with Microsoft Office suite and online record keeping    

Desired Other Skills: 

  • Familiarity with the MassHealth ACO program
  • Familiarity with Federally Qualified Health Centers
  • Experience with anti-racism activities, and/or lived experience with racism is highly preferred
  • Bi-lingual (preferred) 


  • High school diploma or equivalent required
  • Experience working with Medicare, Medicaid, and/or Special Needs populations
  • A valid driver’s license and provision of a working vehicle

Community Care Cooperative (C3) is a 501(c)(3) non-profit, Accountable Care Organization (ACO) governed by Federally Qualified Health Centers (FQHCs). Our mission is to leverage the collective strengths of FQHCs to improve the health and wellness of the people we serve. We are a fast- growing organization founded in 2016 with 9 health centers and now serving hundreds of thousands of beneficiaries who receive primary care at health centers and independent practices across Massachusetts. We are an innovative organization developing new partnerships and programs to improve the health of members and communities, and to strengthen our health center partners.

** In compliance with Covid-19 Infection Control practices per recommendations, we require all employees to be vaccinated consistent with applicable law. * 

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