Community Health Coordinator

Position Description – Community Health Coordinator

Reports to

Director of Behavioral Health Services

Exempt/Non-Exempt Status

Non-Exempt

Security Roles

Case Manager; Patient Navigator

About HOPE Family Health: HOPE Family Health is a Federally Qualified Health Center (FQHC) dedicated to providing comprehensive, high-quality healthcare services to underserved communities. We are committed to improving the health and well-being of our patients through accessible, affordable, and patient-centered care. Our organization plays a crucial role in addressing healthcare disparities and promoting the overall wellness of our community.

JOB SUMMARY: The Community Health Coordinator (CHC) functions as a core member of a collaborative care team that involves the patient’s primary care provider and mental health providers. The CHC provides services which integrate medical, behavioral health, and social health care needs of the patient within a primary care setting and/or behavioral health care setting. This integration involves identifying needs, performing screenings, evaluating patient symptoms, consulting and referral coordinating with outside resources or facilities as indicated (e.g. social services, behavioral health specialty care, substance abuse treatment, etc.)

PRIMARY DUTIES AND RESPONSIBILITIES:

1. Provide mental health care screening, education and services to identified patients to promote improvement in medical and mental health.
2. Facilitate program workflows and improvements to achieve program quality and performance aims.
3. Coordinate care to patients and families who may have difficulty in accessing care, community referrals, and needed resources.
4. Document services rendered in patient electronic records and other databases such as ECW as required.
5. Monitor patients in person at the clinic or by telephone for changes in clinical symptoms and treatment side effects or complications.
6. Conduct and facilitate patient consultations and evaluations with behavioral health providers and communicate resulting treatment recommendations to the patient’s Primary Care Provider or other care team members.
7. Facilitate patient engagement and follow-up in health care.
8. Track patient treatment, follow-up, and clinical outcomes in ECW care management tracking system. Document in-person and telephone encounters in ECW and use the system to identify patients requiring follow-up.
9. Maintain good attendance, be punctual, and work full scheduled shifts
10. Demonstrate respectful, professional, and appropriate behavior that supports a team-oriented work environment.
11. Demonstrate a commitment to the mission, core values, and goals of HOPE and its healthcare delivery including the ability to integrate values of HOPE’s mission while caring for the population it serves.

INTERMITTENT DUTIES:

1. Other duties as assigned by supervisor
2. Attend staff meetings, in-service meetings, team meetings and participate in agency committees and activities as required.
3. Participate in community outreach events and networking opportunities so as to enhance the program’s success in working collaboratively with other community programs and resources.
4. Support reporting requirements per grant contracting requirements.

OFF-SITE WORK:

1. Off-site work is required occasionally.
2. This position does have the option to complete various job tasks off-site with prior approval from supervisor. Such tasks may include, but are not limited to the following: chart documentation, phone consults, conference calls, etc.
3. Employees who participate in off-site work are required to have a confidential designated workspace when completing job tasks.
4. Team Leaders will review each employee’s off-site work classification and details during date of hire, at the employee’s annual review, and as needed throughout the year.

SKILLS/QUALIFICATIONS:

1. Demonstrate ability to collaborate effectively in a team setting.
2. Comfort and flexibility in working with the fast pace of primary care.
3. Ability to effectively communicate with primary medical care providers about mental health issues requiring further treatment.
4. Ability to effectively engage patients in a therapeutic relationship.
5. Experience with screening and assessment for common mental or substance use disorders.
6. Working knowledge of differential diagnosis of common mental or substance use disorders
7. Working knowledge of evidence-base psychosocial treatments for common mental disorders.
8. Working knowledge and experience with brief, structured counseling techniques (e.g. Motivational Interviewing, family systems theory, etc.).
9. Basic knowledge of psychopharmacology for common mental disorders.
10. This role must have a Associate’s degree in health related field; and one to three years related experience working with the uninsured, underinsured, homeless, or other high-risk groups; or equivalent combination of education and experience.
11. Experience working with underserved, transient populations.
12. Experience working with patients who have co-occurring mental health, substance abuse, and physical health problems.
13. Working knowledge of Disability Lifeline, SSI program requirements, and DHS eligibility program requirements.
14. Operate a personal computer.
15. Problem Solving: Frequent problems arise in this position that is outside established policies or bodies of knowledge calling for high-level skills in problem solving.
16. Decision Making: Frequent situations arise in this position calling for careful and analytical judgment.
17. Supervisor: Extensive responsibility for the direct supervision of management, staff and contract employees. Requires the judicious use of delegation.
18. Interpersonal: Must interact with employees, Board of Directors, governmental officials, and the general public.
19. Working Conditions: Works in well-lighted, climate-controlled building. May be subjected to appearance in less than desirable environment and travel in adverse weather conditions. May be exposed to body fluids.
20. Requires sufficient visual acuity to be able to read and write and operate equipment common to this position. Required to read, write and speak English with the ability to speak a foreign language helpful. Requires sufficient hearing level to be able to effectively communicate with people directly or by telephone. Occasionally lift items weighing up to 25 pounds.

Note: This job description is intended to convey information essential to understanding the scope of the Psychiatric Nurse Practitioner position. It is not intended to be an exhaustive list of qualifications, duties, or responsibilities, as other duties may be assigned as needed.

This job description follows the Americans with Disabilities Act (ADA) and the Fair Labor Standards Act (FLSA) (May 1995)

HOPE Family Health Services is an equal opportunity employer who complies with applicable State and Federal civil rights laws and does not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, veteran or disability status.

Many positions at HOPE Family Health Services are funded in-part or in-whole by State or Federal Department of Health and Human Services funding and as such, our organization cannot employ individuals with certain criminal backgrounds or who are on State or Federal exclusion or debarment lists.