Community Health Worker Care Coordinator

• Care Management Activities
• Carries a caseload of approximately 15-20 families annually, adjusting intensity of services based on client risk and identified needs.
• Conducts home visits, virtual visits, and telephonic outreach to develop and monitor individualized Unified Care Plans (UCPs), provide health education and navigation support, and deliver follow-up care coordination.
• Establishes and maintains linkages with SCD specialists, primary care providers, insurers, hospitals, community health centers, schools, faith-based organizations, and local public health agencies.
• Provides culturally responsive education to families and support systems on SCD diagnosis, complications, treatment adherence, and self-management strategies.
• Assists participating families in accessing appropriate health-related social needs (HRSN), including transportation, housing, food security, financial management, employment readiness, and other supportive resources.
• Develops service and engagement plans that support both program goals and family goals, ensuring alignment with the client’s UCP.
• Coordinates referrals and services for high-risk clients with the Program Coordinator to ensure accountability, seamless transitions, and equitable access.
• Maintains accurate records, observes HIPAA and confidentiality requirements, generates data and reports appropriately, and evaluates the effectiveness of services provided.
• Utilizes interpretation and translation services for non-English-speaking families, ensuring clarity and accessibility of care plans and resources.
• Equips families with strategies to navigate health systems and prepares individualized emergency preparedness plans.
• Develops and supports formal communication protocols between families and healthcare professionals (doctors, specialists, nurses, schools, MCOs/insurance companies) to ensure coordinated and consistent care.
• Promotes client and family engagement in community life, education, employment, and social-emotional development, tailoring support to reduce cultural, linguistic, and systemic barriers.

Skills

• Must demonstrate strong organization, time management, and problem-solving skills
• Ability to structure an in-home office and be self-motivated
• Ability to deliver effective individual health education
• Advocate for client and community strengths and needs
• Ability to assess and triage social services quickly
• Advanced proficiency in the Microsoft Office suite and various web-based platforms, with an ability to learn new software, as needed
• Must clear child abuse, criminal history check, and FBI clearance
• Ability to work both independently and in a team environment to meet objectives with minimal supervision
• Ability to acquire information about new systems, organizations, and practices
• Motivational interviewing technique. Bilingual preferred but not mandatory

Experience

• Two years' experience in community health and home visiting is required.
• Demonstrated experience in issues related to home-visiting, children with special health care needs, child development, and technology used to compensate for the loss or diminishment of a vital organ.
• Experience working with diverse populations and low-income individuals.
• Experience with case management documentation.
• Experience providing workshops and training to other professionals.
• Experience successfully coordinating community events with multiple stakeholders.
• Experience in data collection/entry and evaluation monitoring.

Job requirements

• CHW certification preferred or a willingness to pursue certification while in the job.
• Minimum of an associate's degree or two years of relevant experience.
• Maintaining a valid driver’s license and access to a reliable vehicle with current registration and auto insurance are required.
• Reside in or adjacent to a county within the Northeast/Lehigh-Capital Region served by the SCD-CBSS program.

Education Requirement

Bachelor's degree in social work or related field required; or Associate Degree and two years of relevant experience

(if no degree, 5 years relevant experience)

PHMC is an E-Verify and Equal Opportunity Employer