COMMUNITY COORDINATOR

Established in 2005, HealthWorks has been committed to providing a medical home to patients, where medical, dental, behavioral health services and pharmacists work together in a team-based system of care. We strive to improve the quality of our patient’s lives who would otherwise have limited access to health care.

At HealthWorks we recognize and support our diverse group of hardworking people – come be part of something great!

POSITION DESCRIPTION:

Works closely with medical providers, primary care teams, and social service agencies to provide short-term care coordination, connection to resources, and provide patient support in improvement of their health and general well-being through education and provision of coordination of care and social services. Works in both clinical and community-based settings.

ESSENTIAL FUNCTIONS:

1. Provides a warm handoff in the clinic to provide patients with coordination care between mental health services, dental, and pharmacy

2. Assists patients in the clinic and community setting. Communicates to patients/families the purposes of the program and the impact it may have on their well-being. Helps patients/families identify resources to address socio-economic issues that affect their overall health and develop health/social management plans and goals.

3. Documents all patient encounters and contacts made to other agencies on behalf of patients; completes and submits monthly reports; maintains comprehensive electronic patient files, which include patient notes, release of information, assessments and other medical documents acquired on behalf of the patient. Documents activities, service plans, and outcomes achieved by patient in an effective manner.

4. Educates patient on the proper use of the Emergency Room and provides information for alternatives. Coaches patients in effective management of their available community resources and social programs. Assists patient/families in understanding programs and instructions. Motivates patients/families to be active and engaged participants in their health and overall well-being.

5. Assists patients in accessing health-related services, including but not limited to, providing instruction on appropriate use of the medical home and overcoming barriers to obtaining needed medical care and /or social services.

6. Provides support and advocacy during initial medical visit or when necessary to assure patients' medical needs and referrals required are being conveyed. Follows up with both patients and providers regarding health/social services plans.

7. Continuously expands knowledge and understanding of community resources and services. Facilitates patient access to community resources, including locating housing, food, clothing, prenatal classes, parenting, and providers to teach life skills, and relevant mental health services. Assists patients in utilizing community services, including scheduling appointments with social services agencies, and assisting with completion of applications for programs for which they may be eligible.

8. Facilitates communication and coordinates services between providers and the patients/ families in partnership with Care Manager. Coordinates and monitors services, including comprehensive tracking of patients' compliance in relation to care plan objectives.

9. Works collaboratively and effectively within the team. Establishes positive, supportive relationships with participants and provides feedback to other members of the team. Builds and maintains positive working relationships with the patients, providers, nurse case managers, agency representatives, supervisors and office staff, from diverse cultural and socio-economic backgrounds. Works to reduce cultural and socio-economic barriers between patients and institutions.

10. Manages community and/or state programs. This includes Ryan White, local transportation, related programs at LCCP, and others as identified.

11. Grows and maintains relationships with community social need partners and providers.

12. Participate in department meetings and all-staff meetings.

13. Maintain patient confidentiality in accordance with the policies of HealthWorks and as mandated by HIPAA.

14. Performs miscellaneous job-related duties as assigned.

JOB REQUIREMENTS/EXPERIENCE:

Education:

• Bachelor’s degree in health and wellness related fields of study. Degree in social work, nursing, wellness education, etc. preferable.

Knowledge, Skills and Abilities:

• Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
• Knowledge of community agencies and resources. Working knowledge of multi-system outreach programs related to health care delivery, clinical education, and health-related services. Knowledge of transportation and other barriers to care that may be encountered by patient.
• Ability to communicate medical information to health care professionals and care coordinators over the telephone.
• Skill in use of personal computers and related software applications, including email.
• Skill in organizing resources and establishing priorities. Creative and analytical thinking.

Experience:

• Two years’ experience in community health, social work, direct patient care, mental health therapy or other related activities.

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Evenings as needed
• Monday to Friday
• Weekends as needed

Work Location: In person