POSITION SUMMARY: The location for this position is based in Boston and will require reliable transportation. A Community Wellness Advocate (CWA) is a trusted member of the community who helps high risk patients maintain stable health and wellness along a continuum, through integrating and connecting hospital, home-based, and community-based services. CWAs are responsible for providing advocacy and case management services; developing an interdisciplinary care plan based on identified patient needs; facilitating access to social service resources and other internal and external resources; monitoring the patient's progress; and problem-solving with patients to both accelerate and enhance access to concrete supports. CWAs provide in-home or community-based one-on-one, family, and/or interdisciplinary group support to high risk care patients and collaborates with the Patient Care Manager, PCP, and other members of the care team to conduct needs assessments to identify and respond to barriers to the patient's health and wellness. The CCM team including the CWA and CCM RN will be embedded in local primary care practices. The team will partner closely with PCPs, Integrated Behavioral Health Professionals, Pharmacists, and other local resources in the Primary Care Practice to develop multi-disciplinary care plans. Community Wellness Advocate will partner with a CCM RN on a shared patient panel, where the CWA will focus on social determinants of health and the RN will focus on medical/clinical needs. Position: Community Wellness Advocate , Complex Care Department: Population Health Care Management Schedule: Full Time Format: Hybrid The location for this position is based in Greater Boston area and will require reliable transportation. ESSENTIAL RESPONSIBILITIES / DUTIES: * Initiates face to face contact with eligible patients to describe role, explain participation benefits and begin screening process. * Schedules and completes initial hospital, clinic, or community-based (homes, shelters, housing agencies, substance use treatment programs, etc.) visit screening, care plan, and follow up visits and phone calls for enrolled patients within specified timeframes. * Teaches key educational messages using a variety of culturally, linguistically and educationally appropriate strategies, in a variety of settings. * Clearly documents all activities in the patient's record and care management system. * Participates with other staff in activities that include community outreach, presentations to community organizations, development of materials, and phone calls. * Works with patients and providers to set goals for patient's care and provides guidance for patient to achieve those goals. * Reinforces educational messages regarding disease self-management by linking clients with supportive community services and programs. * Presents patients at case review meetings succinctly and logically. * Consults with Patient Care Manager, primary clinical staff, behavioral health teams and / or PCP regarding complex patient situations, demonstrating an understanding of how to solicit and incorporate provider feedback in order to continuously develop the most optimal plan for care. * Demonstrates the ability to function within an inter-disciplinary team (nurse care coordinators, social workers, behavioral health clinicians, physicians, resource specialists, clinical support staff, etc.), connecting the patient with resources as needed. * Records and monitors the participants' progress toward goals within specific timeframes. * Documents assessments and key patient updates in EMR system; documents relevant day-to-day activities and patient data. * Prepares reports and documents as needed or requested. * Assists patients with organizing their records, making follow-up appointments, attending follow-up appointments, and filling their prescriptions. Helps patients fill out applications, for example for Medical Assistance, Housing, and SNAP (Supplemental Nutrition Assistance Program). * Provides advocacy, patient education and successful warm hand offs in accessing community-based and hospital-based programs. * Assists patient in addressing and overcoming barriers with a range of concrete supports, including but not limited to: healthcare support services, behavioral health, financial assistance, child-care and caregiver support, housing, support with utility bills, food, financial entitlements, clothing, transportation, food pantries, violence prevention, social isolation and any other appropriate community resources. * Coordinates with community-based long-term services and supports. * Provide intensive home and community-based outreach, motivational interviewing and goal setting, resource connection and accompaniment to medical appointments as needed to help patients appropriately utilize healthcare. * CWAs may visit patients in hospital and ER settings to facilitate with transitions of care. * Establishes culturally appropriate and trusting relationships with patients and their families. * Participates in all training activities as designated by Community Wellness Manager (CWM). * Attends regularly scheduled supervision and other program assigned meetings. * Develops and maintains strong relationships with the community and community resources to ensure patient access. NOTE: The CWA will not provide hands on care or other services noted as home health services, including but not limited to: performance assessments, provision of care, treatment, or counseling; and/or monitoring of patient's health status. JOB REQUIREMENTS EDUCATION: * HS Diploma with community experience or Bachelor's degree * Driver's license required and access to reliable transportation required EXPERIENCE: * Minimum of 2 years prior healthcare, public health, or community-based experience in a community setting preferred KNOWLEDGE AND SKILLS: * Basic knowledge of healthcare system. * Outstanding interpersonal skills of foremost importance to interact with families and patients. * Interest in community health and outreach. * Exceptional organizational skills; ability to multi-task and work independently and as part of a team. * Demonstrated oral and written English communication skills. * Fluency in Spanish or Portuguese preferable. * Understanding of how language, culture and socioeconomic circumstances affect health. * Desire to work with diverse, multi-cultural and multi-lingual populations. * Proficiency with Microsoft Office applications (i.e. MS Word, Excel, Access, Outlook) and web browsers. Proficiency with data entry and data tracking. Equal Opportunity Employer/Disabled/Veterans