Care Coordination- Community Based Worker

Identifying Components

Status: Non Exempt
Reports to: Social Services Operations Manager
Department: GC211
Dept/Location: Yakima
Salary/Range: Per Salary Scale
Last Revision: January 10, 2025
Core Competencies

People For People employees may be evaluated during their annual performance review on
Core Competencies in addition to their duties contained within their job description. Each Core
Competency will be defined based on the type of work the employee performs. Core
Competencies are as follows:

• Accountable

• Focus on Customer

• Interpersonal Communicator

• Professional

• Team Centered

• Knowledge of Job

• Performance of Job

General Summary

The Community Based Worker (CBW) is a frontline position that works within the community to
connect identified individuals with the local services and support they need to address overall
health, ultimately building and strengthening community resilience by addressing health
disparities, identifying Health-Related Social Needs (HRSN) and improving access to a medical
home and HRSN service providers. This position will work within People For People’s Social
Service department and be a part of a dynamic team of professionals serving the critical needs
of the central Washington region. The CBW requires an individual who has a unique
understanding of the experience, language, and culture of the population being served;
providing culturally appropriate care coordination and resource navigation support to members
of the community. The CBW will receive client referrals, make direct contact with individuals
to complete a comprehensive intake and assessment, determine program eligibility, and

develop a care plan that outlines the goals and specific action plan for success. Specific CBW
training is provided. This position will also participate in community meetings, outreach
activities, and conduct presentations.
The CBW will work within the framework of the regional Accountable Community of Health
system, a structured, cross-sectoral alliance of healthcare, public health, and other
organizations that help individuals and their families to navigate and access needed community
services and increase healthy outcomes. This is through an integrated approach of activities
that promote, maintain, and improve their overall health outcomes.
The goals of this project will be accomplished through the support and integration of the
physical health and social services systems response to individual care needs and an
understanding of a whole-person response to care and help to advocate for systemic changes
to improve overall population health.
The Community Based Worker will be a self-starter that works well both independently and
within a larger team environment and has a passion for working directly with people to improve
lives and overall community health.

Essential Function and Duties

• Provides outreach within the community that educates both individuals and service

providers about the availability of this program and how to access it.

• Receives and processes individual referrals from a variety of sources.

• Determines program eligibility and enrolls individuals into the program.

• Completes a comprehensive evidence-based client assessment/screening to develop

appropriate and responsive care plans.

• Coordinates an array of services designed to improve the health of individuals with high

care needs.

• Engages clients in care coordination activities designed to promote improved utilization

of health care services.

• Educates and empowers clients to better understand the network of social and health

services and how to access them.

• Establishes trusting relationships with clients and their informal support system while

providing general support, encouragement and direction.

• Provides consistent and ongoing follow up and goal setting with clients.

• Provides clients with appropriate referrals to social and health resources.

• Works closely with Community Based Worker team members and the regional

Accountable Community of Health.

• Completes required paperwork, documentation, and project reports within scheduled

due dates.

• Possesses knowledge and comfort working with technology including Microsoft Office

and program specific software (Case Management System).

• Provides outreach and education to communities served by organizing and attending

community forums, meetings, and events; responds to community requests.

• Encourage collaboration and build strong relationships with partner agencies to serve

the community.

• Assist in quality assurance of program by setting and maintaining measurable goals.

• Ensures timely and accurate completion of client paperwork and documentation to keep

the project on track.

• Implements and models organizational policies and values.

• Attends and participates in required meetings and trainings.

• Exhibits excellent working relationships with clients, partners, and staff.

• Perform other related duties as assigned.
  

Job Specifications KSAOs (Knowledge, Skills, Abilities and Other characteristics)

• Governmental Agencies, NGO’s and Geography — Knowledge of government

infrastructure, appropriate Washington State social service agencies, and
nongovernment organizations available as resources to assist clients; Knowledge of
locations/geography of services.

• Making Decisions and Solving Problems — Analyzing information and evaluating results

to choose the best solution and solve problems. Turn problems into opportunities.

• Establishing and Maintaining Interpersonal Relationships — Developing constructive and

cooperative working relationships with others and maintaining them over time.

• Communicating with Supervisors, Peers, or Subordinates — Providing timely

information to supervisors, co-workers, and subordinates by telephone, in written form,
e-mail, or in person.

• Communicating with Persons Outside Organization — Communicating with people

outside the organization, representing the organization to customers, the public,
government, and other external sources. This information can be exchanged in person,
in writing, or by telephone e-mail, zoom meetings, Teams Chat, texting.

• Organizing, Planning, and Prioritizing Work — Work to accomplish specific goals and

create systems to prioritize, organize, and accomplish your work.

• Working with Others — Active participation in larger group/team to work together to

accomplish tasks.

• Documenting/Recording Information — Entering, recording, storing, or maintaining

information in written or electronic/magnetic form.

• Judging the Qualities of Things, Services, or People — Assessing the value, importance,

or quality of things or people.

• Clerical — Knowledge of administrative and clerical procedures and systems such as word

processing, managing files and records, and other office procedures and terminology.

• Demonstrated ability to provide timely, direct feedback to team, supervisor, and partners.

• Ability to respond to clients and partners with patience, objectivity, and a nonjudgmental

attitude.

• Team-centered with effective communication and interpersonal skills, positive attitude

and a caring, compassionate nature.

• Demonstrated ability to follow protocols and procedures.

• Strong verbal and written communication skills (interdepartmental and external).

• Attention to detail, ability to be highly organized.

• Excellent problem-solving skills and ability to multi-task.

• Ability to represent People For People in a positive, professional manner with funders,

network providers, other partners, and the general public.

• Deductive Reasoning — The ability to apply general rules to specific problems to produce

answers that make sense.

• Inductive Reasoning — The ability to combine pieces of information to form general rules

or conclusions (includes finding a relationship among seemingly unrelated events).

• Oral Comprehension — The ability to listen to and understand information and ideas

presented through spoken words and sentences.

• Written Expression — The ability to communicate information and ideas in writing so

others will understand.

Educational/Work Experience Requirements

• Bachelor’s degree in Psychology, Sociology, Public Health, Education or related field, and

• Three years of direct experience working in social/human services or a setting with similar

objectives.

• A combination of education and measurable experience which demonstrates the capacity

to perform the duties of this position may substitute.

• Preferred experience as a community-based professional such as a community health

worker; Promotora de Salud; community-based social worker; nongovernmental,
nonprofit or human services staff: or other community-based professional (e.g. doula,
EMT, peer specialist, recovery coach).

• Bilingual English/Spanish preferred.

• Comprehensive knowledge of community-based social and health services.

Other Requirements

• Employment is contingent upon successfully completing and passing a Pre-employment

Drug Screen and a Washington State Patrol Background Check and/or National

Background Check, Reference Checks, Credit Check if applicable and other required
documents.

• Valid Driver’s License and proof of up-to-date auto insurance

Working Conditions/Physical Requirements

• Duties are performed in an office environment and in the community.

• Travel is required for this position and some work will be performed during and after

standard business hours.

• Physical requirements include the dexterity to reach, stand, climb, squat, twist, finger

keyboards, lift light loads, and the ability to do sedentary work. Sitting, stooping,
walking, standing, light lifting, and extensive computer use may be required.

• Ability to work a hybrid schedule including remote, in office and in the larger

community.

Safety Sensitive: This is not a safety sensitive position.
Disclaimer:
The statements contained herein reflect general details as necessary to describe the principal
functions of this job, the level of knowledge and skill typically required, and the scope of
responsibility, but should not be considered an all-inclusive listing of work requirements. Individuals
may perform other duties as assigned, including work in other functional areas to cover absences or
relief, to equalize peak work periods or otherwise to balance the workload.

People For People is an equal opportunity employer/program and does not unlawfully discriminate
on the basis of race, creed, national origin, disability, sex, marital status, age, or any other
protected status covered by the federal or state law. Please let People For People know if you need
reasonable accommodation in order to perform the essential functions of the job or to participate
in the application process. Auxiliary aids and services are available upon request to individuals with
disabilities. Washington Relay Service 711.

This job description does not constitute an employment agreement between the employer and
employee and is subject to change as the needs of the agency and requirements of the job change.
People For People exercises the right to practice Employment At Will under Washington State law.
Employment At Will states that employment with the organization is voluntarily entered into and
employees are free to resign at any time for any reason. Similarly, the organization is free to
terminate an employment relationship at any time for any reason.