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Overview

About us:

Fallon Health is a company that cares. We prioritize our members--always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, we deliver equitable, high-quality coordinated care and are continually rated among the nation’s top health plans for member experience, service, and clinical quality.

Fallon Health’s Summit ElderCare® is a Program of All-Inclusive Care for the Elderly–PACE for short. PACE, an alternative to nursing home care, is a program that helps people 55 and older continue living safely at home. At Fallon Health, we believe our individual differences, life experiences, knowledge, self-expression and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status and other characteristics that make people unique.

Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE— in the region.

Brief summary of purpose:

The Community Health Worker (CHW) serves as a vital member of the interdisciplinary team within the PACE program, supporting the holistic care of older adults. This role focuses on non-regulatory coordination of services for a designated panel of participants, ensuring seamless communication, service delivery, and participant engagement. Working closely with the Licensed Master’s-level Social Worker, the CHW helps bridge gaps in care, promote wellness, and enhance quality of life for participants.

Responsibilities

Primary Job Responsibilities

Participant Coordination

+ Serve as the primary point of contact for non-clinical service coordination for assigned participants

+ Facilitate communication between participants, caregivers, and the interdisciplinary team

+ Support participants in navigating services such as transportation, home care, meals, and social supports

+ Care Planning Support

+ Collaborate with the Social Worker to implement individualized care plans

+ Monitor participant progress and report changes in status or unmet needs

+ Participate in team meetings and contribute to care planning discussions

+ Community Engagement

+ Conduct home visits and community outreach to assess participant needs

+ Educate participants and families on available resources and services

+ Advocate for participant preferences and cultural considerations

+ Service Coordination

+ Schedule and coordinate non-clinical services such as adult day health, personal care, and durable medical equipment

+ Track service delivery and follow up on missed or delayed services

+ Maintain accurate documentation in compliance with organizational standards

Qualifications

Education:

Bachelor’s degree in Social Work (BSW) or related human services field

License/Certifications

Experience

+ Prior experience in community health, elder care, or case coordination preferred

+ Strong interpersonal and communication skills

+ Ability to work independently and collaboratively in a fast-paced, team-oriented environment

+ Familiarity with PACE model of care or integrated care systems a plus

+ Valid driver’s license and reliable transportation for home visits

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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**Location** _US-MA-Worcester_

**Posted Date** _1 week ago_ _(10/1/2025 12:06 PM)_

**_Job ID_** _8111_

**_\# Positions_** _1_

**_Category_** _Professionals_