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North Shore Community Health Community Health Worker – Care Management in Salem, Massachusetts

Community Health Worker – Care Management

Salem, MA (http://maps.google.com/maps?q=47+Congress+Street+Salem+MA+01970)



We are passionate about our mission here at North Shore Community Health! Our mission is to build healthy communities by providing exceptional care to all. If you are someone who shares our mission and would like to make a real difference in our community, you are a great candidate for us. We currently have a full-time opening for a Community Health Worker-Care Management (CHW). The Community Health Worker (CHW) will provide culturally appropriate health education, counseling, case management, follow up, advocacy, and interpreter services (as needed) for NSCH patients with complex health needs. The CHW collaborates with the Primary Care Team, Medical Social Worker, and other staff, as appropriate, to help coordinate services and improve access to ongoing medical and behavioral health care. The CHW also performs community outreach in order to facilitate linkages with community agencies to address barriers related to Social Determinants of Health. As a team member at our health center, you will work with staff who are racially, ethnically and culturally diverse, so being culturally competent is required. A sense of humor is also very important!


  • Provide culturally competent support services for patients depending on individual needs and preferences. These include but are not limited to:

  • Education/information/assistance in obtaining access to primary care, behavioral health care and other human services

  • Management of urgent non-medical issues (homelessness, detox, reporting suspected child and/or elder abuse, tenant issues)

  • Conducts initial outreach calls to encourage patients and caregivers to participate in specific health care programs

  • Develop and implement outreach plans in collaboration with team colleagues, based on individual, family, and community needs, strengths and resources

  • Use a range of outreach methods to engage individuals and groups in diverse settings (for example: phone, email, text, face to face, etc.)

  • Identify barriers to care and help identify solutions, problem-solving within the health center and with other agencies, as needed

  • Provide patient support and advocacy

  • Initiate and sustain trusting relationships with individuals, families, social networks and primary care team

  • Provide informal supportive counseling and encouragement

  • Provide direct assistance with completion of forms and making appointments

  • Communicate with patients’ primary care and/or behavioral health providers

  • Coordinate and/or provide interpreting for patient appointments within and outside of NSCH on an as-needed basis

  • Provide ongoing monitoring, follow-up and discharge planning, as appropriate, under the direction of the Medical Social Worker, PCP, RN and/or behavioral health provider

  • Provide education on chronic disease management, comprehensive preventive care, and self management goals as directed/provided by the Medical Social Worker, PCP, RN and/or behavioral health provider

  • Develop and keep updated community support services and resource lists for patients and staff

  • Conduct community outreach to:

  • Provide information/make referrals to/coordinate services

  • Identify community resources that provide needed support for patients

  • Provide health education to individuals and groups on prevention and public health risks and problems

  • Educate staff/providers about target population and community characteristics and needs

  • Participate in team and staff meetings at NSCH, as appropriate

  • Work with individuals, family, community members, primary CM and primary care team to address issues that may limit opportunities for healthy behavior. This includes completing Social Determinants of Health (SDOH) screen and other tactics to obtain barriers to care.

  • Meet documentation standards in a timely fashion using the electronic health record, under the direction of the Medical Social Worker, PCP, RN or behavioral health provider

  • Maintain record of patient contacts, as required

  • Use appropriate technology, such as computers, for work-based communication according to North Shore Community Health requirements


North Shore Community Health’s (NSCH) mission is to build healthy communities by providing exceptional care to all. NSCH’s 140 employees provide comprehensive primary care, dental services, behavioral health care, care management, pharmacy, substance abuse disorder treatment, nurse care management, and insurance enrollment assistance services. In 2019, NSCH provided services to 13,272 patients in 63,170 visits. NSCH has 10 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 is on the path to becoming an anti-racist employer.

Workplace Anti-Discrimination and Equal Employment Opportunity Policy

The policy of NSCH is to provide equal employment opportunities by recruiting, hiring, training and promoting applicants and employees without regard to race, color, religion, national origin, sex, age, ancestry, sexual orientation, genetics, pregnancy, marital status, gender identity or expression, disability, handicap, military obligations, veteran status or any other category protected by law (“protected class status”). We affirm that the above policy reflects NSCH's attitude and its intention to do the following:

· Recruit, hire and promote for all job classifications without regard to protected class status;

· Base decisions on employment so as to further the prin­ciples of equal employment opportunity;

· Make promotion decisions are in accord with principals of equal employment opportunity;

· Administer personnel actions such as compen­sation, benefits, transfers, determinations and Center-sponsored training without regard to protected class status;

· Make equal employment opportunities available to qualified disabled or handicapped persons;

· Provide equal employment opportunities to those who are Veterans.


  • Four or more years’ experience and training in a community health center setting, preferred; and/or related experience in health/human services, social services agency

  • BA in health or human services preferred

  • Demonstrated strong communication skills with individuals and/or groups

  • Fluency in English and Spanish strongly preferred

  • Experience working with patients with chronic and behavioral health needs

  • 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

  • Strong analytical, problem solving, planning and prioritization skills

  • Self-motivated and self-directed to work within a team and/or work independently

  • Additional desirable qualities include enthusiasm and passion for helping patients, and empathetic nature

  • Position will be based at Salem Family Health Center; travel may be required to other sites