Care Coordination Specialist

• With other members of the team conduct assessments that include the medical, behavioral, and social needs of the patient in order to identify gaps in care and barriers to accessing resources critical to wellbeing.
• Serve as a liaison between the providers, social service organizations, schools, homeless shelters, hospitals, support groups, etc. and the community to facilitate access to services and improve the quality and cultural competence of the service delivered.
• Provide basic screening, education and brief intervention, facilitating referrals to other health center or community-based resources in accordance with health center protocols for chronic diseases, depression, healthy weight management, and substance use including tobacco use.
• Provide guidance and support relative to transportation, utilities, housing, food security, domestic violence, legal aid, employment, child care benefits, insurance, health care and other relevant bills,
• Educate patients and their families about the need for services, assisting through the diagnostic and treatment process and assisting the RN or Behavioral Health Care Coordinator with the navigation to coordinate required activities.
• Assists patient in scheduling appointments with PCP, other healthcare professionals or community agencies
• Act as a contact point, advocate and resource for patients, their family and their providers, building effective relationships through trust, respect, and communication
• Provide timely verbal and written communications with the provider, care coordinator, patients and their families
• Interact with enrollees as necessary, to identify and address member’s barriers to receiving recommended health services, adhering to treatment plans made by providers, and becoming effective managers of their health
• Monitors and communicates patients’ progress with care plan goals and adherence to appointments made
• Follow-up with provider-identified patients to further assess and address psycho-social barriers that limit the patients’ engagement in their care. Provide patient coordination services to help the patient overcome the barriers to compliance with the plan
• Participate in assigned community based activities, including outreach to potential new patients and connecting them to care and services.
• Schedule, track, follow-up and report diagnostic services and specialist referrals. Close the loop for all referral test and consult results.
• Assist in transitions of care to include tracking and outreach after ER and hospital admissions under the direction of clinical staff
• Work independently on special non-recurring and ongoing projects as needed
• Participate in departmental, team, and organizational meetings, as well as QI projects, as assigned
• Participate in continuing education programs and trainings to meet certification, funding, or regulatory requirements and to meet the needs of the community.

• High school diploma or equivalent required. Associates degree or higher preferred.
• Demonstrated written and verbal communication skills in English
• Bilingual (Spanish) Preferred
• Valid U. S. Motor Vehicle License and reliable transportation to travel to/from outreach activities, if assigned from time to time.
• Min 1 yrs. work or volunteer experience in human services or healthcare with demonstrated knowledge and ability to work with the targeted community. Medical Assistant Certification a plus
• Ability to engage and positively influence others
• Knowledge of both community and healthcare system resources.
• Computer proficiency in Microsoft Office
• Experience in working with an electronic health record preferred

• 401k
• Generous vacation and personal time for eligible employees
• Sick time
• Medical, dental, and vision insurance
• 100% paid Life insurance/AD&D
• 100% paid Long-Term disability.
• Discounts on travel and entertainment!
• Discounts on cell phone service, computer purchases, and more!
• College Tuition Rewards/CMEs
• Company Events & Activities (Annual cookout and holiday party, health and wellness events,” Lunch & Learn’s”, team building, and more!)
• Employee Assistance Program (EAP)
• EyeMed Vision Care Program
• Accident & Cancer Insurance
• Educational development reimbursement
• Discounts on - gym membership, travel & entertainment tickets, electronics, and more!

Community Health Connections