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North Shore Community Health Community Health Worker, Care Management in Salem, Massachusetts

Community Health Worker, Care Management

Salem, MA (



North Shore Community Health (NSCH) is a highly accomplished community health organization that prides itself on its compassionate approach to serving the surrounding communities with comprehensive and culturally sensitive care. With a strong commitment to excellence, NSCH provides:

  • Comprehensive primary care.

  • Dental services.

  • Behavioral health care.

  • Care management.

  • Pharmacy services.

  • Substance abuse disorder treatment.

  • Nurse care management.

  • Insurance enrollment assistance.

NSCH operates service sites at Gloucester, Peabody, and Salem Family Health Centers, ensuring convenient access to care. Additionally, NSCH extends its reach through school-based health centers within the Salem and Peabody School Districts. NSCH collaborates with Bentley Academy, Collins Middle School, Horace Mann School, Bates Elementary School, and the Peabody Learning Academy for behavioral health services.

As a community-based safety net healthcare provider, NSCH actively encourages diversity and welcomes staff members who reflect the rich tapestry of our communities. We highly value the contributions of our team members and offer a wide range of perks and comprehensive benefits. These include health and wellness benefits, tuition reimbursement, loan forgiveness opportunities, and other appealing benefits.

We believe in supporting our employees from day one, and all eligible staff members can take advantage of these benefits right from the start of their employment at NSCH. We aim to foster a supportive and rewarding environment that empowers our team members to provide exceptional care to our communities.

Primary Purpose of Position:

North Shore Community Health (NSCH) is an industry leader in exceptional community healthcare delivery. The Community Health Worker for Care Management (CHW – CM) will provide culturally appropriate health education, counseling, case management, follow up, and advocacy for NSCH patients with complex health needs. The CHW- CM collaborates with the Primary Care Team, ACO team and other staff to help coordinate services and improve access to care with a focus on patients who are identified for care management through ACO programs. The CHW-CM also performs community outreach in order to facilitate linkages with community agencies to address barriers related to social determinants of health.

Essential Functions:

  • Provides culturally competent support services for patients depending on individual needs and preferences. These include but are not limited to:

  • Provides education/information/assistance in obtaining access to primary care, behavioral health care and other human services

  • Management of urgent non-medical issues (connecting urgently to social service agencies for example around housing or food)

  • Conducts outreach calls to encourage patients and caregivers to participate in specific health care programs

  • Conducts and documents relevant patient assessments as designated by health center and ACO programs.

  • Develops and implements outreach plans in collaboration with team colleagues, based on individual, family, and community needs, strengths and resources

  • Uses a range of outreach methods to engage individuals and groups in diverse settings (for example: phone, email, text, face-to-face, etc.)

  • Identifies barriers to care and helps identify solutions, problem-solving within the health center and with other agencies, as needed

  • Provides patient support and advocacy

  • Initiates and sustains trusting relationships with individuals, families, social networks and primary care team

  • Provides informal supportive counseling and encouragement

  • Provides direct assistance with completion of forms and making appointments

  • Communicates with patients’ primary care and/or behavioral health providers

  • Coordinates and/or provides interpreting for patient appointments within and outside of NSCH on an as-needed basis

  • Collaborates with community agencies, for example, behavioral health community partners and long-term services and supports, to improve care coordination

  • Provides ongoing monitoring, follow-up and discharge planning, as appropriate, under the direction of the Nurse Manager, ACO team members, or other care team members.

  • Provides education on chronic disease management, comprehensive preventive care, and self-management goals as directed/provided by the PCP, RN, BH provider or other appropriate team member.

  • Ensures access to or develops/maintains updated community support services and resource lists for patients and staff

  • Conducts community outreach to:

  • Provide information/make referrals to/coordinate services

  • Identify community resources that provide needed support for patients

  • Provide health education to individuals and groups on prevention and public health risks and problems

  • Educate staff/providers about target population and community characteristics and needs

· Participates in team and staff meetings for NSCH and for the ACO

  • Works with individuals, family, community members, primary CM and primary care team to address issues that may limit opportunities for healthy behavior.

  • Meets documentation standards in a timely fashion using the electronic health record and/or the care management platform, under the direction of the Nurse Manager or other designated manager.

  • Maintains record of patient contacts, as required

  • Serves as a resource for other staff members around ACO care management workflows

  • Serves as an expert on community resources for patients and helps troubleshoot relevant patient cases along with other team members.

  • Keeps current with ACO communication/updates around CM and helps foster successful communication between NSCH and the ACO.

  • Uses appropriate technology, such as computers, for work-based communication according to North Shore Community Health requirements.

Non-Essential Functions:

  • Attends periodic staff meetings

  • Adheres to NSCH policies

  • Adheres to NSCH values and principles:


North Shore Community Health’s mission is to build healthy communities by providing exceptional care to all.


Healthy People | Vibrant Communities



We take our responsibility to ourselves, each other, and the NSCH Community very seriously. We understand our individual roles, and positions of power with respect to how others perceive our roles and actions. We hold ourselves accountable when we make mistakes–acknowledging the error, owning it, taking corrective actions, and moving forward. We follow through on what we commit or resolve to do.


Integrity is the foundation of healthy relationships. We are committed to the highest ethical standards: honesty, fairness, respectfulness, and trustworthiness. We are honorable and respectful in dealings with others, and we strive to deal honestly, fairly and in a respectful, ethical, and trustworthy manner when in agreement or disagreement.


Empathy is a deep appreciation for another’s situation and point of view, which is the basis for the golden rule and our intrinsic sense of justice. We strive to bring empathy into our interactions with each other and with our patients.


We see courage as the strength of character to stand up for our convictions and belief system. To have courage is to have the fortitude to take risks and to extend one’s behaviors, actions, and thoughts beyond one’s comfort zone. We appreciate that courage is often required to compromise. Courage is a state of mind to face adverse, difficult, and challenging situations with confidence and positive energy.


NSCH holds its patients in the highest regard. We provide care that is respectful of and responsive to individual patient needs and values. We take the time to listen to concerns, understand what is important, and provide appropriate solutions and care. We do this through coordination and integration of care, collaboration, and teamwork.


NSCH is committed to the health and well-being of its community, patients, and staff. We demonstrate this commitment by constantly striving to align our actions with our mission, vision, and values.

EEO Statement:

We, North Shore Community Health (NSCH), are an equal employment opportunity employer. Our goal is to have a diverse workforce representative of all people, at all job levels, in the organization. We do not and will not make any personnel decisions (like recruiting, hiring, job assignments, and promotions) based on age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity, gender expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law.


  • Four or more years’ experience and training in a community health center setting, preferred; and/or related experience in health/human services, social services agency

  • BA in health or human services preferred, not required

  • Demonstrated strong communication skills with individuals and/or groups

  • Fluency in Spanish and/or Portuguese preferred, not required

  • Experience working with patients with chronic and behavioral health needs

  • Strong computer skills and ability to quickly adapt to using an electronic health record and Microsoft Office applications

  • Maintains strict adherence to the NSCH Confidentiality policy

  • Incorporates NSCH Guiding Principles and Mission Statement into daily activities

  • Complies with all NSCH personnel policies and procedures

  • Strong analytical, problem solving, planning and prioritization skills

  • Self-motivated and self-directed to work within a team and/or work independently

  • Additional desirable qualities include enthusiasm and passion for helping patients, and empathetic nature

  • Employee is expected to travel to any of the NSCH clinical sites as needed based on patient need.