What We Offer:

• Enhanced Benefits Package: Enjoy a comprehensive benefits package that includes discretionary paid time off to ensure a healthy work-life balance, a 401(k) plan with employer match, and a profit-sharing bonus structure that rewards your contributions to our practice’s success.
• Professional Growth Environment: At MFM Health, we are committed to your professional development. We offer continuous opportunities for learning and career advancement in a supportive and collaborative environment.

• Conduct ED discharge follow-up calls and maintain tracking systems to identify frequent ED utilization trends, support value-based care initiatives, and improve patient/provider education and care coordination. 
• Perform outreach and "tuck-in" calls for high-risk patients.
• Engage patients in longitudinal care programs. 

• Complete and follow up on SDOH screenings.
• Assist patients with:
  • Food security resources 
  • Housing support
  • Transportation services 
• Connect patients with community-based organizations. 

• Assist with MassHealth and other insurance applications.
• Help patients understand benefits and coverage.

• Serve as a critical bridge between primary care and behavioral health services by helping identify appropriate behavioral health resources, supporting referral coordination, maintaining knowledge of insurance and access variables, and improving patient access while reducing fragmentation of care.
• Proactively identify and engage patients with unmet mental health or substance use needs, particularly those with frequent ED utilization, in collaboration with providers and the clinical care team. 
• Strengthen patient adherence and follow-through with behavioral health care through consistent outreach and support. 

• Coordinate and support a wide range of patient care needs to improve continuity, reduce gaps in care, and assist with operational follow-through on complex or unresolved tasks.
• Coordinate durable medical equipment (DME), home health/VNA services, specialty referrals, community resources, insurance-related barriers, and other patient support needs. 
• Communicate closely with providers, nursing, care management, and internal departments to ensure timely follow-up and streamlined patient care coordination. 

• Support value-based care and population health initiatives through identification and outreach of high-risk or high-utilizing patients.
• Assist with tracking and reporting trends related to ED utilization, barriers to care, and social determinants of health.
• Support patient engagement and enrollment in care management programs, while helping connect patients to appropriate clinical, behavioral health, and community-based resources to improve overall health outcomes and reduce fragmentation of care.

• Work closely with:
  • Nurse Manager
  • Care Management RN
  • Providers 
  • External partners (hospitals, rehab facilities, community orgs)
• Escalate clinical concerns, worsening symptoms, or urgent patient needs to nursing staff or providers as appropriate. 

• Experience in community health, public health, or care coordination preferred.
• Strong knowledge of community resources and social services.
• Excellent communication and cultural competency skills. 
• Ability to build trust with diverse patient populations. 
• Willingness to obtain Massachusetts CHW certification within (6-12) months of hire required.
• Experience working with underserved or high-risk populations. 

About MFM Health

Our mission at MFM Health is to Make Lives Meaningfully Better. We are continually expanding our practice to provide quality, comprehensive, and compassionate care to patients on the North Shore and beyond. We are committed to hiring passionate individuals who are motivated to succeed in a collaborative, patient-centric culture. We pride ourselves on our commitment to excellence, offering services 365 days a year, drive-thru healthcare, and on-site specialty teams and ancillary services.

At MFM Health, we offer excellent benefits, top-notch training, and a vibrant work environment. We believe in celebrating our employees' successes and regularly gather for company-wide parties and events to foster strong team connections. Join us as we continue to grow, investing in our people, programs, and technology to deliver legendary patient service and further our reputation as the provider, practice, and employer of choice!