Community Health Worker - High Risk Intervention Team

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Location: Beverly, MA
Job ID: 156932-1A
Date Posted: Sep 26, 2019
Category: Clinical Support

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Job Description

Welcome To

Beverly Hospital  is part of a vibrant and growing health care system, recognized as a trailblazer in medicine and a standard bearer in patient experience. It includes an award-winning academic medical center, a superb constellation of community hospitals, home care services, rehabilitation facilities and more.

We are committed to attracting, developing and retaining top talent in a market long recognized and revered as a global leader in health. With a team approach to care, we encourage learning and growth at all levels, and we offer competitive salaries and benefits. We adhere to the principles of a just and fair work environment for all colleagues, where respect is foundational and performance is rewarded.

About the Job

Beverly Hospital, A member of Beth Israel Lahey Health, promotes the culture and philosophy which enables employees to give and receive the best of care.  You can become a part of the team that achieves this success through our CREATE values of Compassion, Respect, Excellence, Accountability, Teamwork, and Empathy. 


Job Description


Funded under a grant from the Health Policy Commission, the Community Health Worker (CHW) position was created to reduce ED utilization by connecting socially complex and behavioral health patients to services.

Working under a licensed social worker, the (CHW) will work directly with patients, families and caregivers. The (CHW) will work with at-risk patients and families in all settings including homes to assess their ability to care for themselves.  They will assist patients in connecting with any and all available resources with the goal of improving the patient’s quality of life and avoiding unnecessary hospitalizations.

Essential Duties:

As part of the Chart II Behavioral Health team, this position:
1. Establishes and maintains a supportive relationship with assigned patients, to include the following:
Engages patient who meet high\moderate utilizer population eligibility via multiple modalities (face to face>telephonic>email) at a frequency determined by patient need
Provides non-judgmental listening and, where applicable, motivational interviewing

2. Provides case management services to include:
Ensures care coordination amongst all providers
Linkages to peer networks/natural supports when able/appropriate
Facilitates and coordinate referral to community social service providers as requested by clinician or care provider
Ensures follow up on referrals
Assists clients in accessing further treatment, self-help groups, housing and services related to physical \behavioral health and other activities of daily living
Provides for or helps the client and his/her family or natural supports with psycho-education and provides educational materials on mental health and substance use disorders and treatment.
Manages CHART Tasks by patient and updates care manager tool
Addresses housing needs (makes an effort to explore and partner with local housing authority for temp and permanent housing)
Helps arrange transportation for patient when necessary

3. Helps implement patient’s treatment plan
Provides input to social worker in constructing and when needed revising treatment plan
Follows treatment plan duties assigned to Community Health Worker
Organizes and communicates patient’s outpatient treatment schedule, including medical and behavioral health
Identifies and addresses obstacles to patient compliance with outpatient treatment

4. Facilitates alternatives to Emergency Department visits
Maintains awareness of patient’s level of functioning and symptoms and reports status to clinician
Facilitates patients being assessed by ongoing outpatient provider or Emergency Psychiatric Services in non-hospital setting, if the patient’s functioning is deteriorating or symptoms are increasing

Scheduled Hours

40 hours per week, day shift.

About Us

The Lahey Model of Care—right care, right time, right place—is exactly what patients, providers and payers need and deserve. Identifying and delivering on this convergence of interests has positioned Lahey Health for further growth. Our model ensures care is highly coordinated and locally delivered, with lower costs and exceptional quality.

Lahey Health is a robust, regional system including a teaching hospital, community hospitals, primary care providers, specialists, behavioral and home health services, skilled nursing and rehabilitation facilities, and senior care resources throughout northeastern Massachusetts and southern New Hampshire. The system has a global presence with programs in Canada, Jordan and Bermuda.

Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.


Knowledge, Skills & Abilities:

Strong networks with Essex County community resources and the ability to create new relationships
Ability to work collaboratively within a multi-disciplinary team unit
High energy and a sense of humor
Ability to overcome obstacles in a positive, productive manner; problem solving skills are critical
For safety and quality reasons, must be able to read, write and communicate effectively in English with patients, visitors and fellow members of the hospital team.

Required Education/Experience:

BA/ BS in psychology, counseling or social work
Preferred:  1-2 years in direct patient care within a Behavioral Health/Substance Abuse setting
Preferred:  Hospital Experience Preferred