Family Support Coordinator/CHW

Who We Are:
Aviva Health is a dynamic and mission-driven federally qualified health center (FQHC). Committed to providing comprehensive and compassionate healthcare services, Aviva Health offers a holistic approach to care, addressing patients' medical, behavioral health, dental, and social service needs. As a vital healthcare resource in the community, Aviva Health fosters a collaborative and supportive work environment where dedicated healthcare professionals have the opportunity to make a meaningful impact on the lives of individuals and families. Join us at Aviva Health and be part of a team that is dedicated to making a difference in the lives of our patients and the community we serve.
Benefits Include:
Monday - Friday Scheduling
Paid Holidays
PTO
Comprehensive Medical, Dental, and Vision Coverage
403(b) Retirement with Employer Match
Training and professional development opportunities
POSITION PURPOSE:
Under the general supervision of the Specialty Clinic Manager, the Family Support Coordinator /Community Health Worker (CHW) serves as a liaison between patients, healthcare providers, community organizations, and social service agencies to improve access to healthcare and essential resources. This position provides health insurance enrollment assistance, care coordination, health education, screenings, and individualized support to patients and families, with an emphasis on maternal and child health.
The Family Support Coordinator/CHW identifies and addresses barriers to care, connects patients with appropriate medical and community services, and promotes family empowerment through education, advocacy, and ongoing engagement. This position also supports community outreach initiatives and develops collaborative relationships to improve health outcomes and access to primary, dental, and behavioral healthcare services.
ESSENTIAL FUNCTIONS:
• Provides accurate, unbiased information regarding health insurance options, including the Oregon Health Plan (OHP), Medicaid, marketplace plans, and other available coverage programs, ensuring patients and families understand eligibility requirements, benefits, and enrollment processes.
• Assists uninsured and underinsured individuals with completing insurance applications, gathering required documentation, resolving enrollment barriers, and following up on eligibility determinations through the Oregon ONE system and other applicable programs.
• Collaborates with patients, healthcare providers, OHP representatives, and state agencies to resolve enrollment concerns, maintain appropriate coverage, and facilitate access to necessary healthcare services.
• Educates patients on navigating their health insurance benefits, accessing covered services, and utilizing the patient portal to communicate with their healthcare team and manage their care.
• Conducts comprehensive assessments of patients' medical, psychosocial, environmental, and social determinants of health (SDOH) needs, identifying barriers to care and coordinating appropriate interventions and community resources.
• Completes individualized family risk assessments, identifies medically or socially high-risk patients, and develops appropriate follow-up plans based on identified needs and available resources.
• Maintains consistent communication with patients and families through in-person visits, telephone calls, and electronic messaging, utilizing motivational interviewing, collaborative goal setting, and supportive education to encourage engagement in care.
• Establishes trusting, supportive relationships with patients and families by demonstrating compassion, respecting individual differences, and providing culturally responsive, nonjudgmental guidance that promotes self-sufficiency and informed decision-making.
• Coordinates individualized services based on patients' physical, emotional, developmental, cultural, and social needs, ensuring timely referrals and follow-up to support continuity of care.
• Facilitates access to primary care, prenatal, interconception, pediatric, dental, behavioral health, and maternal and child health services by assisting with referrals, appointment coordination, and navigation of available resources.
• Identifies transportation, language, financial, and other barriers to healthcare access and connects patients with appropriate transportation resources, interpretation services, and community assistance programs.
• Collaborates with primary care, obstetric, pediatric, nursing, and behavioral health teams to communicate identified social barriers, coordinate interventions, and support patients in following prescribed treatment and care management plans.
• Conducts perinatal depression screenings in accordance with established protocols, communicates identified concerns to the appropriate healthcare provider, and coordinates referrals to behavioral health specialists when indicated.
• Conducts intimate partner violence screenings using established safety and confidentiality protocols, coordinating appropriate support and referrals with Peace at Home advocates and other available resources.
• Provides individualized health education on topics including nutrition, smoking cessation, safe infant sleep and SIDS risk reduction, prenatal and postpartum care, labor and delivery, family planning, lactation, and family involvement.
• Supports patients and families in understanding healthcare recommendations, navigating treatment plans, accessing preventive services, and developing skills to independently manage their health and available resources.
• Develops and maintains collaborative relationships with community organizations, including Communities United Resource Network (CURN), to remain informed of available services and facilitate appropriate patient referrals.
• Coordinates and participates in community outreach activities, enrollment events, and educational initiatives to increase awareness of healthcare services, insurance coverage opportunities, and community resources.
• Participates in the Perinatal Task Force Leadership Team and monthly Perinatal Task Force meetings, contributing to collaborative initiatives that improve maternal and child health services and community coordination.
• Maintains accurate, timely, and confidential documentation of patient assessments, screenings, referrals, enrollment assistance, care coordination activities, and follow-up efforts in accordance with organizational policies and applicable regulations.
• Completes required federal and state consumer assistance training, CHW certification requirements, SDOH education, and other assigned professional development activities to maintain competency and regulatory compliance.
• Collaborates with outreach and enrollment personnel, clinical teams, and organizational leadership to support coordinated workflows, share relevant resources, and improve patient access to services.
• Performs Medical Assistant duties when assigned, provided appropriate training, competency verification, and authorization have been completed, and duties are within the employee's permitted scope of practice.
• Participates in staff meetings, organizational initiatives, and quality improvement activities, identifying opportunities to strengthen patient engagement, community partnerships, and service delivery.
• Attends community events, training sessions, and outreach activities outside standard business hours or at off-site locations as needed.
• Adheres to all Aviva Health policies and procedures.
• Performs other duties as assigned.
PROFESSIONAL QUALITIES:
• Compassion and Empathy: Demonstrates genuine concern for the well-being of patients and families, recognizing individual circumstances and responding with patience, understanding, and sensitivity.
• Cultural Awareness: Respects diverse backgrounds, beliefs, and experiences while adapting communication and support approaches to meet individual needs.
• Initiative and Resourcefulness: Proactively identifies opportunities to assist patients, explores available resources, and takes appropriate action to resolve challenges.
• Organization and Accountability: Effectively manages competing priorities, maintains attention to detail, and consistently follows through on commitments and responsibilities.
• Adaptability: Responds constructively to changing patient needs, community resources, organizational priorities, and unexpected situations.
• Professional Judgment: Recognizes situations requiring additional assistance, maintains appropriate professional boundaries, and exercises discretion when handling sensitive information.
• Collaboration: Contributes to a positive team environment by sharing information, supporting colleagues, and maintaining productive working relationships with internal and external partners.
• Communication: Communicates clearly, respectfully, and effectively with individuals from varying backgrounds, adjusting communication styles to promote understanding and engagement.
• Commitment to Service: Demonstrates reliability, professionalism, and a patient-centered approach while supporting the organization's m

Skills
Regulatory Compliance, Documentation

Employment type
Full-Time

Work arrangement
No