Company Overview
CenterWell Senior Primary is a comprehensive network of doctor’s offices dedicated to providing holistic care for Medicare and Medicare Advantage patients. With a focus on senior primary care, each location features a cross-disciplinary Care Team, including doctors, care coaches, behavioral health specialists, clinical pharmacists, and other professionals offering 24/7 support.
At CenterWell, seniors receive the time, attention, and respect they deserve. Our facilities are thoughtfully designed with special exam rooms, extended appointment times, minimal wait times, and easy access to specialists. We also provide on-site services such as a pharmacy and activity centers, promoting social and physical engagement—essential components of healthy aging.
Our team-based, holistic approach addresses various challenges seniors face, from depression and loneliness to housing insecurity and chronic health conditions. By treating each patient as a whole person, CenterWell fosters better health outcomes and empowers Medicare Advantage recipients to take an active role in their well-being.
About the Job
Join our compassionate community and help us put health first!
As part of an interdisciplinary Care Integration Team (CIT), the Community Health Worker (CHW) plays a vital role in engaging patients and serving as a link between individuals, their communities, and the healthcare system. This includes primary care providers (PCPs), specialists, and other essential services. CHWs implement targeted interventions to remove barriers to healthcare and improve access to essential resources.
This role involves weekly outreach, delivering culturally relevant health education, advocating for patient needs, and coordinating communication between community organizations (such as food banks) and healthcare providers (assisting with scheduling, reviewing wellness visits, and helping patients prepare for appointments).
Key Responsibilities
Care Coordination & Patient Advocacy
- Assess patients’ health and social needs to identify priority areas for intervention.
- Conduct basic health screenings and assist in coordinating further medical evaluations.
- Perform community outreach and home visits to understand patients’ living conditions and barriers to care.
- Educate patients on chronic disease management, behavioral health support, and available social services.
- Assist in navigating healthcare systems, ensuring patients understand their medical information and can ask informed questions at appointments.
- Facilitate communication between patients, healthcare providers, and social service agencies for seamless care coordination (virtually, in-home, or via three-way calls).
- Advocate for equitable access to healthcare, including addressing transportation, language, and financial barriers.
- Empower patients to take an active role in their healthcare and connect with community organizations (e.g., attending a fitness class together for encouragement).
- Promote cultural awareness to ensure inclusive and respectful communication with diverse populations.
Supporting Patient Well-being & Independence
- Identify challenges preventing patients from accessing resources and care.
- Provide education on managing chronic conditions, mental health, and social support options.
- Act as a liaison between patients and care teams, guiding them through healthcare processes.
- Assist in scheduling appointments, arranging transportation, accessing food services, and navigating insurance benefits (e.g., Medicaid, prescription cost reduction).
- Offer emotional support and coaching for patients dealing with complex health issues.
- Work with an interdisciplinary team to create care plans for high-risk patients.
- Ensure all patient interactions are properly documented in medical records while maintaining HIPAA compliance.
Preferred Qualifications
Ideal candidates will bring:
- Community Health Worker (CHW) certification.
- Experience with state Medicaid guidelines and application processes.
- Familiarity with complex healthcare needs of seniors.
- Background in conducting home visits and knowledge of field safety protocols.
Required Skills & Competencies
- Ability to multi-task in a fast-paced environment.
- Adaptability to an evolving role.
- Strong organizational skills.
- Advanced communication skills (oral & written).
- Excellent relationship-building abilities.
- A compassionate approach and dedication to patient advocacy.
- Critical thinking and problem-solving skills to navigate complex healthcare challenges.
APPLY