Care Coordinator, Healthy Steps Program

Community health is about more than just vaccines and checkups. It's about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We're with you every step of the way, with the care you need for each of life's chapters. At Neighborhood, we are Better Together.
As a private, non-profit 501(C) (3) community health organization, we serve over 350k medical, dental, and behavioral health visits from more than 77k people annually. We do this in pursuit of our mission to improve the health and happiness of the communities we serve by providing quality care to all, regardless of situation or circumstance.
We have been doing this since 1969 and it is our employees that make this mission a reality.Regardless of the role, our team focuses on being compassionate, having integrity, being professional, always collaborating, and consistently going above and beyond.If that sounds like an organization you want to be a part of, we would love to have you.
The Healthy Steps Coordinator will join the pediatric primary care team to provide interventions, referrals, and follow-ups for families with patients between 0-5 years old. This role will report to the project director and provide Healthy Steps services to patients, parents, and caregivers. Additionally, this role will build strong relationships with families and providers to increase the efficiency of the medical system and support team-based comprehensive care.
Roles & Responsibilities
Preventative And Responsive Care

• Conducts consultations for needs regarding development and/or behavioral concerns such as sleep, positive parenting, picky eating, etc.
• Maintains the child development support line, including responding and tracking call requests within the designated response time
• Participates in reflective supervision meetings
• Facilitates parent/caregiver groups to introduce program
• Assists patients/parents to participate in their medical and/or behavioral healthcare by overcoming barriers to care
• Deliver and assesses Modified Checklist for Autism in Toddlers (M-CHAT), Patient Health Questionnaire (PHQ9), and the Ages and Stages Questionnaires (ASQ2/3) tools recommended by the Healthy Steps program
• Documents and shares patient screening scores and barriers with primary care and/or behavioral health providers, including appropriate consult documentation is secured in patient medical records
• Participates in Healthy Steps trainings

Referrals & Community Outreach

• Communicates and delivers easy to read information about health and wellness self-help materials and community-based resources
• Creates and maintains community resource directory and database
• Provides referrals and tracks follow ups to help families make successful connections to key resources within the community
• Reaches out to community providers to establish partnerships, including providing and receiving resources to support referrals, warm hand-offs, and ensure appropriate referral criteria
• Assists providers to understand the culture, norms, beliefs, and preferences about patients and their communities by representing the community's voice
• Helps create messages and materials that fit community culture and delivers messages to fit the culture of members
• Participates in required community-wide early childhood and/or mental health meeting or other activities

Team-Based Care

• Participates on the Healthy Steps implementation team, including attending regular team meetings
• Works with the front office administrative staff to ensure the scheduling of the LCSW time is in coordination with provider visits, such as well-child visits
• Engages in continuous quality improvement (CQI) initiatives to ensure the Healthy Steps model is delivered with fidelity
• Collaborates with Healthy Steps implementation team to implement core components
• Maintains open communication with members of the primary care team
• Works with pediatric primary providers around care coordination, goal setting, coaching, and education about key aspects of a child's development
• Provides consultation and/or facilitates training to medical professionals and practice staff regarding early childhood development, early relational health/infant early childhood mental health, and trauma-informed practice
• Utilizes evidence-based approaches when engaging with patients to increase their sense of control over their health, such as motivational interviewing to promote collaboration between patients and their medical/behavioral care team

Documentation & Reporting

• Documents all patient clinical activity and care coordination in electronic health records (EHR)
• Maintains database required to meet Healthy Steps fidelity metrics, including internal and external database files and EHR reports.
• Collaborates with Healthy Steps implementation team to complete required annual site reporting, including analysis of external database and EHR data reports
• Tracks caseload to ensure capacity to deliver the Healthy Steps services within the risk stratified service delivery model, including ensuring exit criteria is met and families/children are elevated to higher levels of care or referred to community providers, as needed
• Ensures documentation is accurate, helpful, and compliant with regulatory requirements and accreditation standards

Requirements
Education/Experience

• Bachelor's degree required; bachelor's degree in early childhood development preferred
• One year of early childhood growth and development, parent-child relational health, infant/early childhood mental health, and family systems experience required.
• Two years' experience working in a healthcare setting required
• Valid CA Driver's License and proof of auto insurance required
• Bilingual (English/Spanish) required
• Master's degree in psychology, social work, counseling, early childhood education, public health, or related field preferred
• Valid CA clinical licensed mental health professional preferred
• Experience working in outreach and customer service within the medical office and behavioral health environments preferred

Additional Qualifications (Knowledge, Skills and Abilities)

• Ability to sufficiently engage members in a variety of settings (phone, in person/homes and/or care settings, such as hospitals)
• Excellent oral and written communication skills.
• Ability to commit to work with underserved populations in a community setting
• Excellent verbal and written communication skills, including superior composition, typing and proofreading skills
• Ability to successfully manage multiple tasks simultaneously
• Ability to collect and enter data for program management, evaluation, and reporting purposes.
• Excellent planning and organizational ability
• Excellent teamwork and relationship building skills
• Ability to work as part of a team as well as independently
• Ability to work with highly confidential information in a professional and ethical manner

Neighborhood Healthcare requires employees to be fully vaccinated (including a booster dose) against COVID-19 and demonstrate proof of vaccination/booster upon hire or receive approval for an exemption based on a medical reason, disability, or religious belief. Proof of booster dose will be contingent upon booster eligibility.
Pay range: $24.78-$30.29 per hour, depending on experience.