Pathways Care Coordinator

Pathways Care Coordinator

Reports to: Health Homes/Care Coordination Manager

We are a very busy pediatric practice, focused on quality care for all children. Our team works well together to support the families that choose us for care while supporting the practice and each other. Maturity and a caring nature are required traits to be a successful part of this team.

Are you a positive enthusiastic individual seeking a position where you can make a difference? Are you looking for a change in pace that allows you to help support children and their families? We have the perfect full-time position available for you!

Job Summary:

The Community Health Worker (CHW) will promote coordination of care and systems navigation support for behavioral health needs and helping families to address a range of stressors through the provision of individualized, relational and strengths-based supports to children, youth and families. The overarching goal is to support children and youth (birth through 18 years old) through short-term interventions within the scope of practice through outreach and engagement, informal counseling, social support and connection to resources addressing Social Determinants of Health.

Key goals are to promote healthy development, empower children, youth and their caregivers/parents around advocating for mental/behavioral health needs, and decrease barriers to accessing resources and services for health related social needs and behavioral health services.

Candidates being considered for the position may be offered a job shadow opportunity to help determine if the role and its responsibilities are a good fit.

Supervisory Responsibilities:

· None

Duties/Responsibilities:

Outreach

· Work closely with clinic staff to identify children/youth and their families to refer to CHW services, with prioritization for special populations such as those who have experienced life stressors, children/youth with special needs, those who have a preferred language other than English, BIPOC who experience greater barriers, etc

· Participate in community outreach to a wide range of sectors and meet with diverse provider pool to build relationships and streamline referrals for families

Informal Counseling

· Support individualized goal setting with children/youth and their families to support health goals and address identified needs

· Describe to children/youth and families the purpose of health care services/recommendations and provide tailored education regarding effective use of the local healthcare and social services systems

· Develop supportive, trusting relationships as means for increasing engagement in primary care and other identified services. Create the opportunity for ongoing contact and relationship building with families via phone/text message check-ins between scheduled visits

· Address barriers faced/voiced in terms of access to any additional referrals or services (e.g., transportation, language)

Health-related social needs

· Identify individualized and comprehensive service needs through in-depth client/family interviews utilizing a social needs assessment

· Utilize knowledge of local community resources and services offered to provide tailored recommendations and referrals (considering cultural and linguistic needs, family geographic location, caregiver comfort and readiness) for client

· Create, update, and maintain each clients’ service/care plan, and other relevant documentation in accordance with clinic guidelines and policies

Other

· Attend staff meetings and work groups to help organize and coordinate outreach

· Maintain consistent documentation of services provided

· Collect data to inform reporting requirements and assess outcomes

· Participate in professional development to support culturally relevant, strengths-based, trauma informed services

· Participate in regular scheduled supervision with a supervisor

· Develop a person-centered health action plan

· Improve self-management of chronic conditions

· Ensure care coordination and care transition

Required Skills/Abilities:

· Organization/ability to multi-task while managing a caseload of multiple families

· Detail oriented

· Punctuality

· Professional behavior/appearance

· Microsoft Office Suite knowledge

· Data tracking/spreadsheet maintaining

· Time Management Skills

· Knowledge of community health resources

· Understanding of general medical terminology and basic medical procedures

· Ability to effectively communicate with a diverse population and establish trust

· Effective active listening skills and social perceptiveness

Education and Experience:

· Bachelor’s degree preferred

· Two years of community experience preferred

· At least 1 year of relevant lived or professional experience working with the under-served population or related experience with some knowledge of the needs and concerns of the population

Physical Requirements:

· Prolonged periods of sitting at a desk and working on a computer

Vaccination proof for MMR, TDAP, Covid-19, and Hep B will be required for staff and patient safety.

Letters of recommendation to submit at interview

Pay: $22-$25 depending on experience

Job Type: Full-time

Pay: $22.00 - $25.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Employee assistance program
• Flexible schedule
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Vision insurance

Work Location: In person

Salary : $22 - $25