ACO Community Health Worker in Pittsfield, Massachusetts at Community Health Programs Inc

Salary Range: $24.00 - $28.00 / hour

Location: Neighborhood Health Center, Pittsfield, MA

The Community Health Worker (CHW) plays a critical, front-line role in supporting patients with complex health and social needs. This role focuses on engaging high-risk and rising-risk patients, addressing barriers related to social determinants of health, and improving connection to primary care and community resources.

CHWs work closely with an interdisciplinary care team to support patients in navigating the healthcare system, building self-management skills, and reducing avoidable emergency department visits and hospitalizations.

This is a relationship-driven, community-rooted, and fast-paced role that requires strong communication skills, resourcefulness, and the ability to build trust quickly.

What You’ll Do (Day-to-Day)

• Meet with patients in the health center and occasionally in community settings (e.g., hospital, court, specialist visits)
• Conduct outreach and follow-up calls, including transitional care management (TCM)
• Assess patient needs, strengths, and barriers to care
• Develop and implement patient-centered care plans in collaboration with the care team
• Support patients in setting and achieving realistic health and life goals
• Coordinate with PCPs, nurses, social workers, and other team members
• Participate in team huddles, case discussions, and interdisciplinary meetings
• Provide in-person support to patients in hospital settings (including emergency department and inpatient units) when needed, particularly for patients who are difficult to reach through traditional outreach methods

Key Responsibilities

Patient Engagement & Support

• Build trusting relationships with patients through consistent, respectful, and culturally responsive communication
• Use motivational interviewing techniques to support behavior change and patient activation
• Engage patients who may be difficult to reach or historically disconnected from care

Care Coordination & Navigation

• Connect patients to primary care, behavioral health, and specialty services
• Facilitate communication between patients and their care team
• Support appointment scheduling, follow-up, and care continuity

Social Determinants of Health (SDOH)

• Identify and address barriers related to:
  • Housing
  • Food access
  • Transportation
  • Behavioral health
  • Substance use
• Connect patients to local resources and community-based organizations
• Advocate for patient needs within healthcare and community systems

Care Planning & Follow-Up

• Develop individualized care plans based on patient needs and goals
• Monitor progress and adjust plans in collaboration with the care team
• Provide ongoing support to reduce emergency department visits and hospitalizations

Documentation & Team Collaboration

• Document all patient interactions in the electronic health record and care management systems
• Maintain accurate and timely records in accordance with organizational protocols
• Actively participate in team meetings, case reviews, and quality improvement efforts

What Makes Someone Successful in This Role

• Ability to build trust and rapport quickly with diverse patient populations
• Strong knowledge of local community resources in the Berkshires
• Skilled in motivational interviewing and behavior change support
• Highly organized and able to manage a caseload of ~50 patients with varying levels of need
• Comfortable working both independently and as part of a team
• Adaptable in a fast-paced, evolving healthcare environment

Essential Skills and Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Qualifications

Required

• High School Diploma or GED
• Valid driver’s license and reliable transportation
• Experience working in community-based services, healthcare, or human services

Preferred

• Associate degree or relevant training in human services or a related field
• Community Health Worker (CHW) certification (or willingness to obtain)
• Prior experience working with high-risk populations, behavioral health, or substance use

Work Environment

• Primarily based in a health center setting with occasional community-based work
• No home visits required
• Fast-paced, team-oriented environment serving high-need populations

Physical Requirements:

• Click here to view the Administrative ADA requirements