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PHMC serves as both a direct service provider to individuals, families, and communities across the region and as an intermediary agent - managing large-scale contracts, government and philanthropic partnerships, and multidisciplinary initiatives that require operational sophistication, strategic leadership, and deep mission alignment.

Job Overview:

Position Type: full-time

Accountability: Program Coordinator

Location: Lehigh/Capital Regions, PA; Frequent travel required

Overview:

The Community Health Worker (CHW) Care Coordinator will be responsible for delivering 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/Capital Regions, which serves several counties in Pennsylvania.

The CHW Care Coordinator will provide client-centered support for children, youth with special health care needs, and adults with Sickle Cell Disease (SCD) across both urban and rural communities. They will assist families with navigating medical, behavioral health, educational, and social service systems, while promoting health literacy, self-management skills, and equitable access to resources.

The CHW Care Coordinator will maintain regular contact with families, collaborate with the Program Coordinator to ensure consistent service delivery, and serve as a liaison between clients, healthcare providers, and community partners. This role emphasizes building trusting relationships, supporting individualized care plans, and participating in outreach efforts to increase awareness of services across the region. This position requires travel throughout the designated counties in the Lehigh and Capital Regions, a valid driver's license, and access to a reliable vehicle with current registration and auto insurance. Some evening and weekend work, as well as occasional overnight travel, will also be required.

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 trainings, including active participation 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.
• Assists 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.
• Participates in bi-weekly SCD-CBSS team meetings (monthly in-person; other meetings via phone/videoconference).
• 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.

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 for navigating health systems and prepares individualized emergency preparedness response 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.
• 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)