Director of Social Care and Community Health Worker Initiatives

Springfield, MA

General Description:

The Social Care and Community Health Worker Initiatives is responsible for the development and integration of the agency’s community care coordination and chronic care management models, including the Accountable Care Organization (ACO) partnership, Community Health Worker (CHW) program, and Social Determinants of Health (SDoH) initiatives. The Social Care and Community Health Worker Initiatives will work under the direction of and in collaboration with the Chief Research & Population Health Officer to support the agency’s mission to eliminate health disparities through evidence-based, culturally-responsive care management and clinical-community linkages. The Director of CHW/Care Management Initiatives will administer a range of grants centered around CHW workforce integration and facilitate an interdisciplinary team of CHWs, Care Managers, and Project Managers to meet a range of grant-, ACO-, and health center-driven priorities to improve health outcomes through integrated care management.

 Reports to:   Chief Research & Population Health Officer

Supervises:    Community Health Workers, Project Coordinators, Project Managers

Salary/Status: Exempt

Hours:            40 Hours/Week

Note: This position is grant-funded.

Minimum Requirements:

  • Master’s degree (or equivalent experience) in Public Health, Health Administration, Social Work, Education, or related field.
  • Oral and written fluency in English (fluency in another language a plus, such as Spanish, Arabic, Russian, Vietnamese, or Nepali).
  • Experience in administration and management of grants or grant-funded programs, including reporting, budget management, and workplan development.
  • Experience with Medicaid ACO, CHW, and care management models and best practices to meet quality improvement and other benchmarks.
  • Prior training/certification in CHW Core Competencies, CHW supervision, and motivational interviewing.
  • Strong theoretical understanding of principles of health equity, SDoH, community development, and social justice.
  • Experience providing clinical supervision of CHWs or other staff delivering direct case management.
  • Excellent written and oral communication skills.
  • Strong professional communication and correspondence skills.
  • Complete proficiency in Microsoft Office (Word, Excel, and PowerPoint) and Google Workspace (Email, Calendar, Drive, Docs, Sheets, and Slides) applications.
  • Strong analytical skills required to identify and address inefficiencies (knowledge of quality improvement and change management principles and methods a plus).
  • Experience managing data (experience with Electronic Medical Record systems a plus).
  • Ability to develop presentations, deliver presentations, and facilitate meetings with internal teams, stakeholders, and grant funders.
  • Superior attention to detail and organizational abilities; ability to validate own work as well as team members’ work.
  • Ability to demonstrate cultural sensitivity with staff, teams, patients, stakeholders, and partners representing diverse cultures, ethnicities, sexual orientations, gender identities, socioeconomic statuses, educational backgrounds, worldviews, literacy levels, and languages.
  • Ability to listen actively, demonstrate responsiveness to team needs/requests, and integrate feedback thoughtfully and promptly.
  • Ability to provide constructive feedback, training, support, and supervision to community-facing staff.
  • Ability to work at a fast pace, manage numerous complex projects and teams, prioritize and accommodate last-minute requests effectively, and tolerate pressure with relative equanimity.

Principle Responsibilities and Duties:

  • Strengthen and integrate the agency-wide CHW workforce by creating policies and workflows that link efforts across inter-departmental initiatives and are guided by grant-, ACO-, and health center-driven best practices and priorities.
  • Standardize the CHW program across multiple departments and with all CHW leadership (e.g., Behavioral Health, Public Health Programs, Clinical, ACO Care Management, Research); oversee and develop streamlined approaches to CHW supervision, workflow, case management, documentation and population health data reporting, and training.
  • Provide organization-wide clinical supervision and leadership to support all existing community care coordination teams (e.g., CHWs, CHW supervisors) and chronic care management teams.
  • Provide direct supervision to Generalist CHWs, and project staff (Managers, Coordinators).
  • Provide leadership and support to executive and staff teams with ACO projects, including management of ACO committee representation (e.g., Direct Care, Patient and Family Advisory, and Clinical Interoperability Committees), alignment of ACO initiatives with care management workflows, and adherence to ACO and health center quality and care management deliverables.
  • Coordinate existing and emerging grants and programs focused on CHW initiatives or workforce development. Grants administration responsibilities will include development and monitoring of workplans for multiple grants, budget/fiscal management, data collection and reporting, execution of grant objectives and deliverables, and funder communications/relations.
    • Exercise a high level of organization and attention to detail to ensure timely tracking, budget oversight, completion, and submission of all grant deliverables.
    • Maintain positive relationships and responsiveness to grant project officers and technical assistance providers, and ensure successful completion of all required meetings and communications
  • Collaborate with grant- and program-specific Managers/Directors to support the programmatic integration of CHWs, community care coordination, and chronic care management.
  • Ensure communication and coordination related to community care coordination and chronic care management is shared, integrated, tailored as appropriate across all departments:
    • Organize and facilitate monthly all-team meetings to include all CHWs, CHW supervisors, Nurse Care Managers, and Nurse Care Coordinators to provide high-level case management review, review of care coordination best practices, data-driven identification of gaps, disparities, or areas needing improvement.
    • Maintain regular availability for individual CHW supervisors needing support to efficiently oversee their CHW teams.
    • Coordinate and disseminate information regarding CHW and care management trainings, certification requirements, and other policies/requirements affecting agency-wide community care coordination and chronic care management.
  • Track and report on agency-wide training and certification across all CHW and care management teams.  
  • Develop systems to document, track, and report on agency-wide productivity of CHW and care management teams; collaborate with departmental leadership to ensure demonstrated and measurable cost/benefit of CHW and care management programs.
  • Collaborate with Analytics team to identify and utilize population health data reports, dashboards, and care management tracking tools to closely monitor and grow SDoH screening, response, and linkage to community resources.
  • Oversee CHW workforce sustainability and growth by collaborating with Human Resources and Directors/Managers to streamline CHW staffing across programs, interview, hire, engage new CHWs in orientation and training, and ensure career development and advancement for CHWs (e.g., develop a “Lead CHW” role).
  • Identify areas needing improvement across CHW programs to guide future grants, programs, and training opportunities for CHWs and Care Managers/Coordinators; collaborate with Chief Research & Population Health Officer, department Directors/Managers, and grant writer to sustain and expand CHW and care management funding opportunities.
  • Maintain a robust agency awareness of emerging trends, resources (e.g., 413Cares, care management tools, state/national requirements) and training available to grow and advance community care coordination and chronic care management programs.
  • Facilitate meetings, deliver presentations, and foster partnerships with interdisciplinary internal teams, grant funders, and community partners.
  • Continuously expand knowledge and understanding of community resources and services, public health prevention practices, and evidence-based intervention programs.
  • Develop and strengthen partnerships and bi-directional referral systems with community-based service providers.
  • Provide representation across a variety of regional CHW networks (e.g., New England CHW Coalition, Hampden County CHW Coalition, Holyoke Community College) to develop and strengthen stakeholder relationships and CHW programming. 

Working Conditions:

  1. This position may require the ability to work long and arduous hours.
  2. This position requires the ability to use a computer workstation, viewing a CRT.