Community Outreach Coordinator Per Diem

St. Luke’s University Health Network; Allentown (Lehigh County); On-site; USD 42,000 - 64,000; Full time

Job summary

St. Luke’s University Health Network is seeking a Care Management Outreach Coordinator to help patients and their families access community resources and adopt healthy behaviors.

The role emphasizes in-person home visits, community outreach, and telehealth support, with a focus on assisting patients through integrated care management and social support. The position involves coordinating with care managers, building community partnerships, and advocating for individuals while maintaining

Qualifications

• High School diploma with 3 years' patient care or community resource experience.
• Associate degree with 2 years' patient care or community resource experience preferred.
• Valid driver's license and reliable transportation.

Responsibilities

• Assist care plan tasks and navigate social determinants of health barriers.
• Develop and maintain relationships with community agencies and resources.
• Provide in-person home visits, community visits, and telephonic outreach.
• Screen for home safety and health concerns and assess eligibility for services.
• Document thoroughly in the electronic medical record and support telehealth activities.

Skills

Care coordination

Community outreach

Health coaching

Telehealth support

Patient engagement

Education

High School Diploma/GED

Associate degree (preferred)

Tools

MyChart

Job description

St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care. The Care Management Outreach Coordinator (CMOC) will be responsible for helping patients and their caregivers navigate and access community services, other resources, and adopt healthy behaviors mainly through in person home visits or community-based visits. The CMOC supports the care managers through an integrated approach to care management and community outreach. The CMOC provides social support and informal light health coaching, advocates for individuals and community health needs with government agencies or health service providers, supports telehealth visits and health screenings.

JOB DUTIES AND RESPONSIBILITIES:

• Complete assigned care plan tasks as assigned by the Care Manager to address SDOH barriers and work toward meeting care plan goals.
• Develops and maintains relationships with community agencies and resources.
• Responsible for establishing trusting relationships with patients and their families while providing general support and encouragement to the patient through in person home visits, community-based visits, and telephonic outreach.
• Screens for home safety and health concerns.
• Compliant with annual network or department competencies focusing on health coaching patients on self-management tools related to chronic illnesses and appropriate health coaching.
• Telehealth visit assistance with technology, access to SLUHN.org, MyChart access and gathers medication bottles, patient questions for review by RN Care Manager
• Assists patients and RN Care Manager with medication review during home or community visits.
• Utilizes motivational interviewing technique and scripting when outreaching the patient or caregiver.
• Attend provider and community appointments with patients as directed by Manager
• Provide referrals for services to community agencies utilizing Findhelp as appropriate.
• Maintain timely, accurate, complete, and consistent documentation appropriate to role in the electronic medical record.
• Assist patients with completing applications and registration forms.
• Maintains expertise in telehealth procedures, participates in staff meetings, participates in network and/or department committees or special projects as assigned.
• Participates in precepting new employees as assigned.
• Participates in peer educational presentations.
• Attends scheduled rounding and site visits and on-site meetings or education as required.
• Screens the need for referrals and determine eligibility for services, according to government and local program guidelines.
• Supports Network and department goals and objectives.
• Appropriate time management with regard to home visits and documentation.
• Contributes and maintains knowledge of current SLUHN care management programs available to patients and families.
• Completes Community Health Worker course within 1 year of hire date.
• Maintains confidentiality of all materials handled according to Network/ Entity policies.
• Demonstrates financial responsibility and accountability through the effective and efficient use of resources in daily procedures, processes, and practices.
• Complies with Network and departmental policies regarding attendance and dress code.
• Other related duties as assigned.
• Must have a valid driver’s license and reliable transportation.

PHYSICAL AND SENSORY REQUIREMENTS:

• Must have the ability to sit for 2 hours per day, and up to 1 total consecutive hour.
• Must be able to stand for 6 hours total per day and up to 4 consecutive hours.
• Be able to walk six total hours per day and up to 30 total consecutive minutes.
• Must have the ability to frequently use fingers and hands.
• Must have the ability for touching as it relates to feeling objects by touching with skin, particularly that of the fingertips.
• Must have the ability for hearing as it relates to normal conversation, high frequency, and low frequency hearing sounds.
• Must have the ability for seeing as it relates to general vision, near vision, color vision, and peripheral vision.

EDUCATION AND EXPERIENCE:

• High School Graduate/GED with 3 years of patient care or community resource experience required.
• Associate degree with 2 years of patient care or community resource experience preferred.

Thank you for your interest in St. Luke's!!

St. Luke's University Health Network is an Equal Opportunity Employer. Founded in 1872, St. Luke’s University Health Network (SLUHN) is a fully integrated, regional, non-profit network of more than 23,000 employees providing services at 16 campuses and 350+ outpatient sites. With annual net revenue in excess of $4 billion, the Network’s service area includes 11 counties in two states: Lehigh, Northampton, Berks, Bucks, Carbon, Montgomery, Monroe, Schuylkill and Luzerne counties in Pennsylvania and Warren and Hunterdon counties in New Jersey. St. Luke’s hospitals operate the largest network of trauma centers in Pennsylvania, with the Bethlehem Campus being home to St. Luke’s Children’s Hospital. SLUHN is the only Lehigh Valley-based health care system to earn Medicare’s five-star ratings (the highest) for quality, efficiency and patient satisfaction. It is both a Leapfrog Group and Healthgrades Top Hospital and a Newsweek World’s Best Hospital. The Network’s flagship University Hospital has earned the 100 Top Major Teaching Hospital designation from Premier 13 times total and eleven years in a row, including in 2023 when it was identified as THE #4 TEACHING HOSPITAL IN THE COUNTRY. In 2021, St. Luke’s was identified as one of the 15 Top Health Systems nationally. St. Luke’s is the ONLY health care institution in the Lehigh Valley to be named a Top Workplace regionally repeating the exclusive honor for the third year in a row. Also, for the third straight year, St. Luke’s has been a Top Workplaces in the Philadelphia Region by the Philadelphia Inquirer, ranking 9th in the large employer category for 2025 and the only health care system in PA to receive this award. In 2025, St. Luke’s was recognized as a national Top Workplaces by USA Today, three years in a row, including the 3rd best health care system in the nation in 2023 and 2024. Lastly, in 2025, St. Luke’s was named a Top Workplace in New Jersey for the third year in a row. Learn More Here.