Job Description

Position Purpose:

Under the direction of the Embedded Care Coordination Manager, the Embedded Care Coordinator Community Health Worker (ECC-CHW) is a trusted member of the community who assists individuals, families, and internal teams who are experiencing difficulty adjusting to illness, disability or post-acute care. ECC-CHW engages patients, creates a trusting relationship, and provides care coordination to connect members with resources for Behavioral, Medical, and/or Social Determinants of Health (SDOH) needs. The ECC-CHW will make patient visits in the home, community, Emergency Department, hospital or other settings and works with the patient to set health goals and closely communicate with the member’s Primary Care Physician. The ECC-CHW provides support and assists members in understanding the resources and services available to them.

Essential Duties and Primary Accountabilities:

  • Provides face to face and telephonic care coordination services to high risk patients that have social determinants to health care
  • Provides care coordination and care management services to patients in the community, homes and health care settings that patients access.
  • Schedules and completes initial assessment, develops a patient-centric plan of care and schedules follow-up within specified timeframes
  • Initiates telephonic or face to face contact with high risk patients of all ages to conduct a Care Needs Screening.
  • Evaluates Care Needs Screening responses and make appropriate referrals to internal care management programs or to external resources.
  • Records and monitors the participants’ progress toward goals within specific timeframes
  • Assists patients with organizing their records, making follow-up appointments, and filling their prescriptions.
  • Helps patients fill out applications, for example for Medical Assistance and SNAP (Supplemental Nutrition Assistance Program)
  • Provides advocacy, patient education and support in accessing community-based and hospital-based programs
  • Makes referrals to case managers, as appropriate, and/or refers patient’s family to community support services and resources.
  • Utilize resources of public and private agencies and community organizations to meet the needs of patients and families.
  • Collaborate with youth and family service agencies at the local, county and state level including but not limited to schools, special education services, DCFS, family court systems.
  • Embeds within practice; builds relationship with physicians, nurses, and staff by working within the practice on a daily basis as a team member
  • Proactively communicates with the practice regarding upcoming appointments for identified patients and coordinates to join appointment
  • Maintains an open level of communication with treating physician and case managers in planning and directing each patient’s treatment program
  • Influences change within practices to build a successful embedded program (confidence, leadership, independence, etc.)
  • Facilitates weekly Huddles with practice manager
  • Teaches key educational messages in-person and telephonically and utilizes teach back methods to measure and ensure patients understanding
  • Clearly documents all activities in the patient record
  • Provides concise and thorough documentation through psycho/social assessment and progress notes, including changes in medical psycho/social functioning, progression and attainment of goals, referrals to internal and external agencies, and contact/involvement with patient’s family. Demonstrates cultural sensitivity and respect for the patient
  • Acts as a liaison and advocate between the patient, family, and
  • Provides clinical consultation to physicians, professional staff and other teams members/supervisors to provide optimal quality patient care and effective operations
  • Addresses barriers to follow through on health care including, but not limited to: homelessness/housing instability, financial resources, transportation, child care, etc. and places referrals to community based resources as necessary
  • Demonstrates cultural sensitivity and respect for the patient

Work Related Experience:

  • Experience working with the needs of vulnerable populations who have chronic or complex bio-psychosocial needs
  • Experience working with disadvantaged populations, preferred
  • Experience in a managed care environment and case management experience, preferred
  • Must be able to effectively communicate, present and explain complex material with patients, family members, case managers, treating physicians and community organizations
  • Must possess the interpersonal skills to engage individuals and families in helping relationships.
  • Must be able to cope with the pressure of time limitations while respecting the needs of the patient and the requirements of the organization/department
  • Ability to take action in solving problems while exhibiting judgment and a realistic understanding of issues; able to use reason, even when dealing with emotional topics
  • Ability to remain open-minded and change opinions on the basis of information, perform a wide variety of tasks and change focus quickly as demands change, and manage transitions effectively from task to task.
  • Ability to travel, including valid driver’s license and auto liability insurance coverage according to company policy.
  • Must possess a strong belief in an organizational culture that encourages valuing and best service excellence practices demonstrated through personal behavior and work ethic
  • Ability to work in several databases and to comply with established documentation requirements
  • Exceptional organizational skills; ability to multi-task and work independently and part of a team
  • Demonstrate ability to prioritize, multitask, and work in a rapidly changing environment with multiple demands

Specialized Knowledge:

  • Possesses knowledge and expertise of the healthcare system and resources available in the area in which BH-ECC is providing care coordination/care management services
  • Demonstrates knowledge and understanding of the impact of the community and culture on health, illness, health practices, health beliefs, access to care and participation in treatment and services
  • Working knowledge of community based and government services and resources need to assist patients in accessing services and addressing potential Social Determinants of Health
  • Able to accurately sort through data and think through issues in a time-pressured environment.
  • Able to focus on a specific event or activity for up to four (4) hours at a time without interruption.
  • Able to maintain a calm and collected presence while addressing the concerns from an internal and external customer
  • Able to accurately learn and retain new information, knowledge and skills.
  • Able to efficiently manage multiple tasks, with varying degrees of priority, at the same time.


  • High school diploma required, Bachelor’s degree preferred
  • BLS Certified (CPR/First Aid)

Years of Experience:

  • Required minimum 2 years of experience in behavioral health management and/or acute behavioral health care setting focusing on outpatient/inpatient utilization, case management and discharge planning

Application Instructions

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