Community Health Coordinator at Pediatric Associates – Plantation, Florida

PRIMARY FUNCTION

The Community Health Coordinator partners with patients, families, clinic staff, and the Licensed Clinical Social Worker (LCSW) to identify and address Social Determinants of Health (SDOH) needs and barriers to care that impact patient wellbeing. The CHW serves as a trusted liaison between patients and community resources, assisting with system navigation, resource linkage, and follow-up support to improve access to care, adherence to care plans, and overall health outcomes. This role focuses on connecting patients and families with community-based services, government programs, and social support. The CHC provides non-clinical care coordination, education, and advocacy under the supervision of the LCSW and works collaboratively with interdisciplinary teams to support patient-centered, culturally responsive care.

ESSENTIAL DUTIES AND RESPONSIBILITIES

This list may not include all the duties that may be assigned.

1. SDOH Screening & Needs Identification - Assist in identifying social needs such as food insecurity, housing instability, transportation barriers, financial strain, and access to benefits using approved screening tools.

1. Resource Navigation & Linkage - Connect patients and families to community resources, social services, government programs, and nonprofit organizations to address identified needs.

1. Care Coordination Support - Support care coordination efforts by communicating with patients, families, care teams, and community partners to help ensure services are accessed and barriers are addressed.

1. Benefits & Program Assistance - Assist patients in completing applications, forms, and documentation required for community, federal, state, and local assistance programs.

1. Patient Education - Provide basic education about available community resources, program eligibility, and how to navigate healthcare and social service systems.

1. Follow-Up & Engagement - Conduct follow-up calls or outreach to ensure patients were able to access referred services and to identify ongoing barriers.

1. Care Plan Support - Reinforce care plans developed by clinical staff and the LCSW by supporting patients in meeting social and practical needs that impact health.

1. Cultural Mediation & Advocacy - Advocate for patients and families, helping bridge cultural, linguistic, and system-level barriers.

1. Documentation - Document all patient interactions, referrals, and outcomes in the electronic health record (EHR) and CRM systems according to organizational standards.

1. Team Collaboration - Participate in team meetings, case discussions (as appropriate), and interdisciplinary care coordination activities under LCSW supervision.

1. Community Relationship Building - Maintain an updated directory of community resources and develop relationships with local agencies and service providers.

1. Outreach & Community Engagement - Participate in community outreach efforts, health events, and educational activities to increase awareness of available services.

1. Training Participation - Attend required training on SDOH, trauma-informed care principles, confidentiality, and community resources.

1. Escalation of Clinical Concerns - Immediately report mental health crises, safety concerns, or complex psychosocial issues to the LCSW or clinical staff for assessment and intervention.

1. Customer Service - Provide compassionate, respectful, and patient-centered support to all patients and families.

1. Data Tracking - Track referrals, outcomes, and follow-up status using approved metrics.

1. Other Duties - Perform additional Patient Resources or SDOH-related duties as assigned.
   

QUALIFICATIONS

EDUCATION:
High school diploma or GED required. Associate’s degree in human services, public health, social work, or related field preferred.

EXPERIENCE:
2 years of experience in community outreach, social services, healthcare support, patient navigation, or a related field preferred.

LICENSURE / CERTIFICATION

• Community Health Worker certification preferred (if applicable in state)

• No clinical licensure required

LANGUAGE

• Bi-lingual in English and Spanish strongly preferred.

KNOWLEDGE, SKILLS AND ABILITIES

• Knowledge of community resources, social services systems, and public assistance programs

• Strong communication and interpersonal skills

• Ability to build trust with diverse populations

• Cultural humility and sensitivity to socioeconomic challenges

• Basic understanding of trauma-informed approaches

• Ability to maintain professional boundaries

• Organizational and time management skills

• Ability to work under supervision and escalate clinical concerns appropriately

• Basic documentation and computer skills

• Customer service mindset

TYPICAL WORKING CONDITIONS

• Patient-facing

• May rotate working in the office and remote/telework.

• If remote, this job must be U.S. based.

OTHER PHYSICAL REQUIREMENTS

• Vision

• Sense of sound

• Sense of touch