High Acuity Community Health Worker

Under the supervision of the Manager of Integrated Navigation Services, the CHW - Public Health provides clinical and social determinants of health referrals and navigation to low-income people living with HIV/AIDS (PLWH). This role will primarily work with those who are not virally suppressed, not well connected to medical care, and at high risk for housing instability.

Responsibilities:

• Provide clients with easily accessible and low-threshold services that operate within the harm reduction framework and assist clients in overcoming other barriers to service delivery, including assisting clients on a walk-in, triage, and community/home visits on an as-needed basis.
• Review, and when applicable complete, comprehensive assessment of clients’ social determinants of health (SDoH) needs and acuity including housing, legal, nutrition, employment, transportation and medical care.
• Conduct service planning and implementation, case coordination, case conferencing, case monitoring and follow-up services for those identified as out of care.
• Develop innovative strategies to retain and engage people in medical care in collaboration with medical care teams.
• Collaborate with supportive staff to provide seamless continuum of services.
• Work collaboratively with clinical providers and financial assistance coordinators to assist clients with scheduling HIV follow up appointments, lab and medication requests, accessing Ryan White funding, state insurance, and other financial services for core medical and supportive services.
• Refer clients to services that address SDoH needs, including internal and external housing search and legal services, nutrition resources, state benefits, and transportation assistance.
• Work proactively and intentionally to coordinate with Medical, Drug User Health, Sexual Health, Housing, and Medical Case Management colleagues to ensure seamless continuum of care and services for client.
• Communicate with DPH Epidemiologists and complete case reports for new HIV infections.
• Build cooperative referral relationships and maintain regular communication with area agencies and organizations that serve our target population so clients can take advantage of Linkage to Care services.
• Work collaboratively with Housing and Medical Case Management colleagues to share resource information.

• Bachelor’s degree in a related field or 1 year of equivalent lived experience
• Experience providing direct service to diverse populations including people living with HIV/AIDS, people using substances, people experiencing homelessness, people with mental health diagnoses, people who are bilingual/bicultural and people with varying gender identity, gender expression and sexual orientation.
• Self-motivated; ability to work independently and proactively.
• Ability to juggle multiple tasks under pressure and deadlines.
• Ability to work patiently and persistently with clients and colleagues in order to ensure follow through and to function as part of a team.
• Ability to work harmoniously and effectively with colleagues, patients, clients and vendors across the spectrum of diversity, including but not limited to race, ethnicity, color, gender identity, sexual orientation, age, socio-economic status, national origin and immigrant status, religious or spiritual identity, disability (physical, mental, emotional and developmental), veteran status, and/or limited English proficiency.
• Willingness to contribute towards Fenway’s efforts in becoming an anti-racist organization and promoting a culture dedicated to ongoing development in service of humility, equity, diversity, inclusion, and belonging, where differences are acknowledged and valued.

Preferred Qualifications:

• Two years of experience in a related field
• Experience in case management and/ or housing advocacy
• Bilingual in Haitian Creole/ English or Spanish/Englis
• Valid Massachusetts driver’s license
• HIV/AIDS awareness and sensitivity