Community Health Worker Care Coordinator

Job Overview

The Community Health Worker (CHW) Care Coordinator will deliver direct outreach, education, and care coordination services for the Sickle Cell Disease Community-Based Services and Support (SCD-CBSS) program in the Family Services Department for the Lehigh/Capitals Regions, serving several counties in Pennsylvania.

Responsibilities

• Prepares and maintains records, reports, and/or data on participating individuals and families affected by SCD.
• Maintains regular contact with enrolled clients through phone, email, home visits, video conference, and other client-preferred methods of communication.
• Works as part of the SCD-CBSS team, functioning effectively in a structured environment with self-paced tasks.
• Attends all required meetings and training, and actively participates in outreach presentations, conferences, and community events.
• Documents all client contacts using required written forms: intake and assessment forms, progress notes, referral forms, Unified Care Plans (UCPs), engagement plans, discharge and transition plans.
• Communicates formally every week with the Program Coordinator to review case progress, challenges, and strategies for alignment.
• Aids in the development of new approaches to improve program delivery, content, and evaluation implementation.
• Attends local and regional meetings, trainings, and networking events relevant to Sickle Cell Disease and Community Health Work.
• Collaborates with HPC’s Outreach and Engagement team to support culturally responsive outreach and education strategies, including the development and distribution of brochures, flyers, and digital tools tailored to the SCD community.
• 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.
• Aids 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.
• Collaborates 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.
• Promotes client and family engagement in community life, education, employment, and social-emotional development, tailoring support to reduce cultural, linguistic, and systemic barriers.

Skills

• 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.
• Advanced proficiency in the Microsoft Office suite and various web-based platforms.
• Ability to learn new software, as needed.
• Clearance for child abuse, criminal history check, and FBI clearance.
• Ability to work both independently and in a team environment to meet objectives with minimal supervision.
• Motivational interviewing technique.

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.

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.
• 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).