Behavioral Health Care Coordinator and CHW

Position Summary:

The Behavioral Health Care Coordinator and Community Health Worker serves as a trusted liaison between West Cecil Health Center (WCHC), patients, and community-based resources. The Behavioral Health Care Coordinator and Community Health Worker supports care coordination and outreach activities that improve patient outcomes, reduce barriers to care, and strengthen connections to community and behavioral health services.

The Behavioral Health Care Coordinator and Community Health Worker plays a crucial role in connecting patients and their families with essential mental health and substance abuse services, both within West Cecil Health Center (WCHC) and through external community resources. This role emphasizes outreach and relationship-building with individuals from underserved populations. The overarching goal is to create a supportive environment that promotes the health and well-being of patients and their families by leveraging robust community connections, and optimizing resource utilization.

• Growth and Advancement Opportunities
• Company Sponsored Events
• Employee Engagement Committees
• WCHC offers a compressive benefit package including:
  1. Medical, Dental, and Vision insurance
  2. Health Reimbursement Arrangement
  3. Employer paid Life and AD&D and Disability insurance
  4. 401K with employer match
  5. Generous Paid Time Off and Volunteer time
  6. Paid Holidays
  7. Education reimbursement

Key Responsibilities:

• Provide compassionate, unbiased, and culturally competent support to vulnerable and historically marginalized populations.

• Acts as a liaison between patients, their families, insurance companies, and community resources to ensure access to necessary services and support.

• Conduct outreach calls and community-based follow-ups to support patients with care coordination and linkage to services.

• Assist in identifying patients due for follow up BH medication management or Therapy appointments

• Track and document outreach efforts, referrals, progress and patient interactions in the Electronic Health Record (EHR) within 48 hours of contact.

• Support care teams by helping patients understand and act on care plans, medication adherence, and treatment goals, including for those enrolled in MAT programs.

• Provide appointment reminders, help arrange transportation, and address barriers to accessing care or community resources.

• Establish and maintain trusting relationships with patients, families, and community partners while providing encouragement and follow-up support.

• Educate patients about community assistance programs, health literacy, and available resources.

• Collaborate with providers and clinical staff to ensure coordinated, patient-centered care.

• Maintain HIPAA compliance and protect patient confidentiality at all times.

• Perform other duties as assigned to advance the goals of the Behavioral Health Department

• Participate in data-driven outreach campaigns and quality improvement activities related to the Behavioral Health department

• Coordinating follow-up after positive behavioral health screenings (e.g., PHQ-9, GAD-7, SBIRT), and assisting with warm handoffs to counseling, MAT, and community recovery resources.

Essential Functions

• External Referral Management

  • Alerts providers about expiring Psychiatric Rehabilitation Program (PRP), Intensive Outpatient Program (IOP) and Partial Hospitalization Program (PHP) authorizations.

  • Completes and submits PRP/IOP/Residential Rehabilitation Program (RRP) /Transitional Care Management (TCM) referrals for both adolescents and adult patients.

  • Conducts reauthorizations, appointment scheduling, and communication with external facilities.

  • Connects patients with external facilities or services for specialized or intensive care.

• Hospitalization Tracking

  • Tracks hospitalizations for Behavioral Health patients and informs providers about any Behavioral Health patients who are hospitalized.

  • Scans and sends hospital notes and other relevant documents to providers, and follows up on discharges.

  • Arranges and facilitates provider to provider discussions as requested.

  • Schedules follow-up appointments for Behavioral Health related hospitalizations.

• Mental Health Status Checks

  • Conducts mental health status checks on patients between office visits as requested by providers.

  • Reconciles medications with patients upon provider request.

  • Informs patients about crisis resources and connects them with providers or mobile crisis services if necessary.

  • Assists with Emergency Petitions and follows up through the discharge process.

• Resource Coordination

  • Oversees access to mental health services, substance abuse services, and addresses social determinants of health.

  • Assists patients in obtaining multiple resources by contacting community agencies and facilitating their direct outreach.

  • Helps Medicaid patients with enrollment in medical transportation services as needed.

  • Connects patients with appropriate support groups and external services (such as Applied Behavioral Analysis (ABA) therapy, etc.

  • Maintains directory and informs providers about new community resources available to patients.

• Depression Remission

  • Arranges follow-up appointments for patients needing PHQ9 assessments between reassessment periods for quality assurance goals

  • Informs therapists about patients needing re-assessment within their designated windows to meet measurement requirements (BH Care Gaps).

• Additional Duties:

  • Attends meetings as requested by various departments, noting new community resources or changes.

  • Joins weekly Behavioral Health provider meetings to offer support and resources.

  • Prepares and completes the Behavioral Health bulletin board monthly, aligning with the mental health awareness calendar and providing resource handouts.

  • Follows the mental health awareness calendar and helps coordinate events like the Out of the Darkness Walk and National Recovery Month.

  • Bilingual employees: Provide communication and translation assistance to patients within the scope of the role.

  • Provides coverage for B