Opportunity Overview

North Shore Community Health (NSCH) is an industry leader in exceptional delivery of community healthcare. The Community Health Worker, Population Health (CHW-PH) plays a dual role providing CHW case management services for patients as well as participating in population health and performance improvement work as part of the Quality Improvement team. They will provide culturally-appropriate education, care coordination and linkages to health care and community services for NSCH patients with complex health needs and those with recent involvement in hospital care. Additionally, they will utilize reporting and patient registries to provide outreach related to care and coding gaps; to facilitate patient engagement; and to improve overall health center performance.

The Organization

North Shore Community Health is a high performing community health organization that prides itself on being a compassionate community health center, serving its surrounding communities with comprehensive and culturally competent care.

NSCH offers comprehensive primary care, dental services, behavioral health care, care management, pharmacy, substance abuse disorder treatment, nurse care management, and insurance enrollment assistance services. NSCH has ten services sites: Gloucester, Peabody and Salem Family Health Centers; the school-based health centers at Salem High School and Peabody Veterans Memorial High School; and behavioral health only services at the Bentley Academy, Collins Middle School, Horace Mann School, Bates Elementary School, and the Peabody Learning Academy. NSCH offers competitive benefit plans and as a community-based safety net healthcare provider, NSCH welcomes staff who mirror the diversity of our communities and continues on its path to furthering its commitment to being an anti-racist organization.

Mission

North Shore Community Health’s mission is to build healthy communities by providing exceptional care to all.

Vision

Healthy People | Vibrant Communities

Values

Accountability

We take our responsibility to ourselves, each other, and the NSCH Community very seriously. We understand our individual roles, and positions of power with respect to how others perceive our roles and actions. We hold ourselves accountable when we make mistakes–acknowledging the error, owning it, taking corrective actions, and moving forward. We follow through on what we commit or resolve to do.

Integrity

Integrity is the foundation of healthy relationships. We are committed to the highest ethical standards: honesty, fairness, respectfulness, and trustworthiness. We are honorable and respectful in dealings with others, and we strive to deal honestly, fairly and in a respectful, ethical, and trustworthy manner when in agreement or disagreement.

Empathy

Empathy is a deep appreciation for another’s situation and point of view, which is the basis for the golden rule and our intrinsic sense of justice. We strive to bring empathy into our interactions with each other and with our patients.

Courage

We see courage as the strength of character to stand up for our convictions and belief system. To have courage is to have the fortitude to take risks and to extend one’s behaviors, actions, and thoughts beyond one’s comfort zone. We appreciate that courage is often required to compromise. Courage is a state of mind to face adverse, difficult, and challenging situations with confidence and positive energy.

Respect

NSCH holds its patients in the highest regard. We provide care that is respectful of and responsive to individual patient needs and values. We take the time to listen to concerns, understand what is important, and provide appropriate solutions and care. We do this through coordination and integration of care, collaboration, and teamwork.

Commitment

NSCH is committed to the health and well-being of its community, patients, and staff. We demonstrate this commitment by constantly striving to align our actions with our mission, vision, and values.

EEO Statement:

We, North Shore Community Health (NSCH), are an equal employment opportunity employer. Our goal is to have a diverse workforce representative of all people, at all job levels, in the organization. We do not and will not make any personnel decisions (like recruiting, hiring, job assignments, and promotions) based on age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity, gender expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law.

https://www.nschi.org/wp-content/uploads/2022/03/nsch_eeo-policy-statement-dec-2021.pdf

Responsibilities:

• Provide case management services appropriate to the CHW role for patients identified by the health center or accountable care organization (ACO).
• Outreach to patients by phone or through other means (text, email, face-to-face) to engage patients in care management or to address health care gaps/needs.
• Engage with patients in-person at the health center at the time of their scheduled appointments or at other times agreed upon by the patient, CHW and/or the patient care team.
• Educate/assist patients in obtaining access to primary care, behavioral health care and other services
• Conduct patient screenings related to quality metrics such as/not limited to Social Determinants of Health (SDOH) and behavioral health screenings and utilize other appropriate methods to identify/address barriers to care.
• Help identify solutions around barriers to care, problem-solving within the health center and connecting patient with community agencies/services.
• Assist patients with completion of forms, making/keeping appointments and accessing transportation for health care appointments.
• Coordinate patient appointments within and outside of NSCH.
• Monitor ED and hospital utilization reports on a daily (or otherwise determined) basis and outreach to patients to coordinate post-hospital care.
• Provide education on chronic disease management, preventive care, and self-management goals within the CHW scope and as directed.
• Identify community resources, make referrals for patients, ensure organization has access to updated list of community resources and serve as a point-person for other staff around available resources.
• Communicate with external community partners (CPs) and coordinate review of CP care plans by primary care teams.
• Work on projects and serve as a point person on initiatives such as those around quality of care, clinical workflows, risk adjustment, patient empanelment and care coordination, to meet annual health center and ACO goals.
• Utilize online data management systems, such as DRVS/Arcadia, or collaborate with data analyst, to create patient registries, validate patients’ empanelment to our health center, and track/resolve gaps in patient care and risk adjustment/coding.
• Track patients due for health care services to identify and resolve gaps in care through patient outreach and/or records reconciliation.
• Request records from outside providers, obtain releases of information from patients and collaborate with referrals team as needed to ensure records related to gaps in care are obtained.
• Communicate with primary care teams and other relevant staff to provide updates and get input on quality and care management initiatives and to assist with new workflows.
• Attend monthly quality improvement committee, ACO/population health and health center team meetings as needed and play a role in other relevant quality efforts across the health centers.
• Foster successful communication between NSCH and the ACO.
• Meet documentation standards in a timely fashion using the electronic health record and/or other care management platform (Arcadia).
• Use appropriate technology, such as computers, for work-based communication according to North Shore Community Health requirements.
• Other duties as assigned.

• Experience in a community health center setting and/or related experience in health/human services, social services agency preferred.
• BA in health or human services preferred.
• Demonstrated strong communication skills with individuals and/or groups.
• Spanish or Portuguese skills preferred.
• Experience working with patients with chronic behavioral health needs a plus.
• Strong analytical, problem solving and planning skills.
• Ability to successfully prioritize multiple projects on an ongoing basis.
• Self-motivated and self-directed to work independently as well as ability to engage with various teams across the organization.
• Strong computer skills and ability to quickly adapt to using an electronic health record and Microsoft Office applications.
• Maintains strict adherence to the NSCH Confidentiality policy.
• Incorporates NSCH Guiding Principles and Mission Statement into daily activities.
• Complies with all NSCH personnel policies and procedures.
• Additional desirable qualities include enthusiasm and passion for helping patients, and empathetic nature.
• Based at Salem Family Health center but will be expected to float to the various NSCH sites.

As a health center, NSCH expects all employees to receive all required vaccinations and health screenings each year. Moreover, as a condition of employment, all employees are expected to be vaccinated against COVID19, including providing proof of having received the COVID19 vaccine, unless a religious or medical exception is granted. All prospective employees are required to be vaccinated before their first day of employment, and proof of vaccination record must be provided with prehire paperwork. To request an accommodation from the vaccine requirement or if you have any questions about this mandate, please contact the Human Resources Department at hr@nschi.org .

At North Shore Community Health, we are dedicated to building a diverse workforce. Are you excited about this role but feel that your past experience does not align perfectly with every requirement in the job description? We encourage you to apply! Your skills may be suited for this or other roles here at North Shore Community Health

Living on the North Shore

With facilities in Salem, Peabody, and Gloucester, NSCH offers access to New England’s Coastal charm, while being just thirty minutes outside of Boston. The North Shore is connected to the city via the Rockport Commuter Rail line, which makes stops in Salem and Gloucester. The North Shore has plenty to offer, with a rich history and thriving cultural scene.

For Information Please Contact:

Ella Mae Kaba

Talent Acquisition Program Manager

North Shore Community Health

(857) 320-6761

ella.kaba@nschi.org