Specialist, Community Care Program

Legacy Community Health; Houston (TX); On-site; USD 42,000 - 56,000; Full time

Benefits offered by this job

Paid Time Off & Paid Company Holidays

Medical, Dental, Vision & Life Ins.

Flexible Spending Account (FSA)

403(b) Retirement Plan with Company &

Short-Term & Long-Term Disability

$0 Copay for Legacy Provider visits

$0 Copay for prescriptions filled at‑%

Travel Insurance

Pet Insurance

Subsidized Gym Membership

Job summary

Legacy Community Health in Houston, TX, is seeking a Community Care Program Specialist to coordinate patient care, link clients to medical and social services, and support families through care plans. The role emphasizes empathetic, client-centered assistance and collaboration with healthcare teams.

The position requires a CHW certification, a high school diploma or related bachelor’s degree, and at least 1–5 years of experience in family services.

Qualifications

• High School Diploma or equivalent with a minimum of 5 years of relevant experience; or a Bachelor's Degree with a minimum of 1 year of relevant experience preferred.
• Community Health Worker (CHW) Certification is required.
• 1 year of experience working with families, assessing psychosocial and health needs, and making community referrals.

Responsibilities

• Assess each referred client's medical and psychosocial history and current service needs.
• Provide interventions, referrals, and assistance in linking to medical, psychosocial, and basic needs services.
• Participate in the creation of patient-centered care plans for referred patients and their families.
• Document ongoing follow-ups to support progress towards care goals in a timely manner.
• Advocate for clients and families to help decrease service gaps and remove barriers to services.
• Collaborate with Legacy staff and healthcare providers for effective system navigation.
• Work together with managed care organizations and community-based agencies to facilitate access to social supports.
• Conduct home/site visits to identify needs for services.
• Educate patients and community members about the healthcare services provided by Legacy.
• Assist clients in developing and utilizing independent living skills.
• Provide guidance on basic safety planning and risk reduction.
• Monitor the efficacy and quality of services through periodic re-evaluation.
• Complete monthly reports for the Health Connect programming.
• Document services provided in EHRS client records within 72 hours.
• Participate in Legacy's Performance Improvement and Quality Assurance Program.

Education

High School Diploma or equivalent

Bachelor's Degree in a related field

CHW Certification

Job description

Benefits

• Paid Time Off & Paid Company Holidays
• Medical, Dental, Vision & Life Insurance
• Flexible Spending Account (FSA)
• 403(b) Retirement Plan with Company Match
• Short-Term & Long-Term Disability
• $0 Copay for Legacy Provider visits
• $0 Copay for prescriptions filled at Legacy Pharmacies
• Travel Insurance & Pet Insurance
• Subsidized Gym Membership
• And much more!

Location: Legacy Montrose Allen Parkway - 2929 Allen Pkwy. Houston, TX 77019

Specialist, Community Care Program - Job Overview

Schedule: Monday-Friday (8AM-5PM)

At Legacy Community Health, we know that true healthcare means understanding the whole person and their unique needs. As a Community Care Program Specialist, you'll be an integral part of a passionate team dedicated to transforming the lives of our patients by providing exceptional care coordination services. Your work will focus on helping to bridge gaps in care, ensuring that every patient feels supported, empowered, and connected to essential healthcare resources.

As you support our patients on their health journeys, you'll find fulfillment in your role while enjoying a collaborative environment that values every voice and fosters growth. Here's what you can look forward to:

• Becoming part of a compassionate team that values collaboration and mutual support.
• Making a meaningful impact in the lives of patients and their families.
• Exploring opportunities for professional development and mentorship.
• Contributing to a mission-driven organization that prioritizes community health and well-being.
• Enjoying a work-life balance that allows you to thrive both personally and professionally.

Key Responsibilities

• Assess each referred client's medical and psychosocial history and current service needs.
• Provide interventions, referrals, and assistance in linking to medical, psychosocial, and basic needs services.
• Participate in the creation of patient-centered care plans for referred patients and their families.
• Document ongoing follow-ups to support progress towards care goals in a timely manner.
• Advocate for clients and families to help decrease service gaps and remove barriers to services.
• Collaborate with Legacy staff and healthcare providers for effective system navigation.
• Work together with managed care organizations and community-based agencies to facilitate access to social supports.
• Conduct home/site visits to identify needs for services.
• Educate patients and community members about the healthcare services provided by Legacy.
• Assist clients in developing and utilizing independent living skills.
• Provide guidance on basic safety planning and risk reduction.
• Monitor the efficacy and quality of services through periodic re-evaluation.
• Complete monthly reports for the Health Connect programming.
• Document services provided in EHRS client records within 72 hours.
• Participate in Legacy's Performance Improvement and Quality Assurance Program.
• Demonstrate respect and regard for the dignity of all patients and colleagues.
• Promote effective working relationships and contribute positively to the team dynamic.
• Attend required training and workshops to enhance your skills.
• Travel between Legacy locations and community-based agencies as needed.
• Maintain a clean and organized workspace according to Legacy standards.
• Work within the framework of a primary care medical home.

Minimum Qualfications

• High School Diploma or equivalent with a minimum of 5 years of relevant experience; or a Bachelor's Degree in a related field with a minimum of 1 year of relevant experience preferred.
• Community Health Worker (CHW) Certification is required.
• 1 year of experience working with families, assessing psychosocial and health needs, and making community referrals.

About Legacy Community Health

As the largest Federally Qualified Health Center (FQHC) in Southeast Texas, Legacy Community Health has been delivering comprehensive, high-quality, and affordable health care for nearly 40 years.

With more than 50 clinics across the Greater Houston and Gulf Coast region, we continue to grow strategically and invest in our communities. By innovating how care is delivered, we've stayed at the forefront of connecting our communities to health- every day, in every way.

At Legacy, we know our success is powered by our people. We're always looking for talented, passionate individuals who want more than a job—they want a meaningful career that makes a real impact.

Explore our open positions and see if a career at Legacy is right for you.

Core Employee Expectations

At Legacy Community Health, our mission—Driving healthy change in our communities—guides everything we do. To fulfill this mission, every team member is expected to embody the following core attributes in their daily work, regardless of role or department:

Approachable & Collaborative

We bring our expertise without ego. In a collaborative healthcare environment, humility fosters trust and teamwork. Our employees value diverse perspectives, seek input from others, and are unafraid to acknowledge when they need help. We stay grounded in our purpose: to serve patients and communities with compassion and humility.

Driven & Committed

We are driven by a deep commitment to excellence in patient care and organizational improvement. Our employees take initiative, embrace challenges, and go the extra mile to support our mission. Whether improving patient outcomes, streamlining processes, or stepping up in times of need, we are always striving to drive healthy change-within ourselves, our teams, and the communities we serve.

Perceptive & Thoughtful Communicators

We value emotional intelligence as much as clinical or technical skill. Our team members demonstrate sound judgment, cultural sensitivity, and the ability to navigate complex situations with empathy and professionalism. They communicate clearly and respectfully with patients, families, and colleagues, building trust and fostering a safe, inclusive environment for all.