Specialist, Community Care Program

Legacy Community Health•Houston, TX

1d•Onsite

About The Position

At Legacy Community Health, we know that true healthcare means understanding the whole person and their unique needs. As a Community Care Program Specialist, you’ll be an integral part of a passionate team dedicated to transforming the lives of our patients by providing exceptional care coordination services. Your work will focus on helping to bridge gaps in care, ensuring that every patient feels supported, empowered, and connected to essential healthcare resources. As you support our patients on their health journeys, you'll find fulfillment in your role while enjoying a collaborative environment that values every voice and fosters growth. Here’s what you can look forward to: Becoming part of a compassionate team that values collaboration and mutual support. Making a meaningful impact in the lives of patients and their families. Exploring opportunities for professional development and mentorship. Contributing to a mission-driven organization that prioritizes community health and well-being. Enjoying a work-life balance that allows you to thrive both personally and professionally.

Requirements

High School Diploma or equivalent with a minimum of 5 years of relevant experience; or a Bachelor's Degree in a related field with a minimum of 1 year of relevant experience preferred.
Community Health Worker (CHW) Certification is required.
1 year of experience working with families, assessing psychosocial and health needs, and making community referrals.

Responsibilities

Assess each referred client's medical and psychosocial history and current service needs.
Provide interventions, referrals, and assistance in linking to medical, psychosocial, and basic needs services.
Participate in the creation of patient-centered care plans for referred patients and their families.
Document ongoing follow-ups to support progress towards care goals in a timely manner.
Advocate for clients and families to help decrease service gaps and remove barriers to services.
Collaborate with Legacy staff and healthcare providers for effective system navigation.
Work together with managed care organizations and community-based agencies to facilitate access to social supports.
Conduct home/site visits to identify needs for services.
Educate patients and community members about the healthcare services provided by Legacy.
Assist clients in developing and utilizing independent living skills.
Provide guidance on basic safety planning and risk reduction.
Monitor the efficacy and quality of services through periodic re-evaluation.
Complete monthly reports for the Health Connect programming.
Document services provided in EHRS client records within 72 hours.
Participate in Legacy's Performance Improvement and Quality Assurance Program.
Demonstrate respect and regard for the dignity of all patients and colleagues.
Promote effective working relationships and contribute positively to the team dynamic.
Attend required training and workshops to enhance your skills.
Travel between Legacy locations and community-based agencies as needed.
Maintain a clean and organized workspace according to Legacy standards.
Work within the framework of a primary care medical home.