Community Health Coordinator

Minimum Education
B.S. (Required)

Minimum Work Experience
0 years No experience (Required)

Required Skills/Knowledge
Ability to motivate others towards achieving goals. Knowledge of community resources.
A strong sense of and respect for confidentiality involving both clients and fellow employees.
Ability to work in a variety of settings with culturally-diverse families and communities with the ability to be culturally sensitive and appropriate.
Ability to work independently with strong sense of focus, task-oriented, nonjudgmental, open personal qualities, clear sense of boundaries.
Good interpersonal, oral and written communication skills, ability to establish rapport.
Proficient at keyboarding and facile with Microsoft Office Excel, Access and Power Point.
Spanish speaking preferred

Functional Accountabilities
Ambulatory Care Management Outreach

• Under the direction of clinical staff (care coordination or clinical practice), locates members when attempts to contact have failed and initiates contact by visiting home/places of last contact

• Initiates patient contacts in conjunction with the case management plan including patient contacts to close gaps of care and discharge follow-up and refers appropriate information to Care Manager

• Provides outreach and education to appropriate members and develops relationships to connect them to needed resources and applicable care management programs

• Under the direction of the Ambulatory Nurse Care Manager completes needs assessments, post-discharge questionnaires, care management screenings, and other clinical screening tools.

Collaboration with Medical Home and Care Management Team

• Under the direction of the Ambulatory Nurse Care Manager completes data collection, needs assessments, post-discharge questionnaires, care management screenings, and other clinical screening tools.

• Collaborates with clinical care team as well as care management care team to define role appropriate interventions to meet the patient's care management needs

• Interact and respond to inquiries from families, payers, external providers, and medical team by answering questions and explain information clearly and thoroughly.

• Informs care management team of any changes in patient location or status in a timely manner

Ambulatory Care Management Administrative Support

• Provides administrative support to the Medical Management team including answering phone queues and other general clerical functions

• Faxes information to external care providers (such as specialty pharmacies or home health agencies) under the direction of the care management team.

• Performs data entry and data retrieval activities as required.

Documentation and Data Management

• Documents patient consent for Care Management.

• Facilitate tracking/contact with patients who