Peak Vista Community Health Centers is a non-profit healthcare organization whose mission is to provide exceptional healthcare to people facing access barriers.  We provide primary care services (medical, dental and behavioral healthcare) through 26 outpatient health centers in El Paso, Teller, Lincoln, Adams, Arapahoe, Elbert, and Kit Carson counties.  We deliver care with our strong “Hospitality” culture.  Our organization has over 800 employees and serves 90,000 patients in the Pikes Peak & East Central Plains region.  Peak Vista is accredited by the Accreditation Association for Ambulatory Health Care, Inc. (AAAHC).

Job Summary (Essential Functions)
Summary:  To serve as a liaison between providers, programs, and families and to provide support services to families that are "at risk," including teen/developmentally-disabled moms, newborns born with Neonatal Abstinence Syndrome and/or special needs.  Responsible for assisting at-risk families in achieving maximum success with their children through a collaborative process involving the parent, children, family and/or care-givers as well as providers and other clinical support staff and community partners.  This process includes assessment, planning, facilitation and advocacy.  Through communication and the identification of available resources, assists at-risk patients in identifying and obtaining services necessary to meet their physical and emotional needs.  This will in turn reduce the incidences of child abuse.  At-risk factors may include more than one of the following:   Adverse Childhood experiences (ACES); Previous/prior DHS or foster involvement; History of abuse, neglect, no known social support; lives alone, homeless; Poor nutrition; Financial concerns; Repeated emergency department visits and or hospitalizations; Low functional status or cognitive deficit; Mental illness or substance abuse; Pervasive history of noncompliance.

Job Duties:
Assesses clients' psychosocial needs including socioeconomic and care deficits and makes the appropriate referral for services. 
Assesses the client's willingness to learn.
Coordinates service planning with the client, family or caregiver to maximize health care responses.
Coordinates and follows up on referrals.
Advocates and builds rapport with community agencies.
Coordinates communication with members of the healthcare team and educating the client, family or caregiver and care team about treatment options and community resources as well as psychosocial needs and socioeconomic status and deficits.
Coordinates care with various internal and external health teams and community partners.
Mentors and shares information with families in order to strengthen the parent/child relationship, assist parents in improving skills to optimize the home environment, educate parents in child care, growth and development.
Develops training materials and providing training for FV volunteers, PV staff and partner agencies on educational materials and positive parenting techniques.
Other duties may be assigned.
This position involves driving to a client's home for assessment and follow-up and accompanying patients to off-site appointments as needed.  Scope of authority includes: providing resources coordination, follow-up, patient education, and self-management education services to clients and to serve as a consultant to medical staff and requesting support from professional staff when required.


Qualifications

Education:    Minimum 4 year degree in Human Services field or related field.
Work Experience:    Minimum of 3 years' experience in case management, crisis intervention or client centered counseling and extensive knowledge of community resources required.
Cognitive Skills (Language, Math, Reasoning Ability):    Excellent language, reasoning and thinking abilities.
Computer Skills:.    Word, Excel, Electronic Health Record.  
Other Skills:     Knowledgeable of community resources, sensitivity to low-income and diverse groups of people, ability to work with families from a strength-based model and strong interpersonal skills.  Bilingual  Spanish preferred. Self-motivated.  Valid driver's license and insured automobile required.
Certificates & Licenses:    CPR Certification

Physical Demands
Frequent standing and walking, occasional long periods of sitting, moderate bending, moderate energy requirements, and frequent fine motor skills.  Looking at computer screen continuously for long periods of time, hearing within normal range. Able to travel from clinic to clinic as required and make home visits as needed.  Must be able to lift 50 pounds.


*Successful candidates will complete pre-employment screening; which includes, but is not limited to a Criminal Background check. Peak Vista Community Health Centers is a drug and alcohol free workplace an an Equal Opportunity Employer.