As a vital member of the care team, Care Coordinators support the organization’s quality and value-based care efforts through coordination of internal and external services, referral management, and basic health education interventions.
Coordinates internal and external services for patients in collaboration with the care team.
Utilizes evidence-based screening tools to identify and document social determinants of health (SDH) and health-related social needs (HRSN) and provides resources and referrals to internal and external partners best equipped to address identified barriers.
Knows and maintains the database of community resources available to STRIDE’s patient population.
Documents and communicates in a “closed loop” fashion with both patient and care team from initial interaction to closure of the episode or completion of goals.
Conducts patient interaction(s) with respect, collaboration, and confidentiality utilizing basic principles of motivational interviewing when appropriate.
Provides basic health education using evidence-based educational resources from nationally recognized sources or the Electronic Health Record and refers patients to appropriate internal or external resources for further education and support when indicated.
Manages internal and external referrals in accordance with organization policies, procedures, and standards including maintenance of the referral partner database, referral processing, follow-up with external agencies and providers to “close the loop”, retrieving and indexing reports.
Contributes to population health efforts including targeted outreach and scheduling of patients based on specific criteria such as the presence of a chronic condition, wellness visit due, preventative health needs, recent emergency department or hospital visit, or at provider/organization request.
Follows departmental standard workflows.
Supports quality improvement activities including those informed by external partners, payors, accreditors, and regulators as assigned.
Completes all other duties as assigned.
Education And Experience
At least 1 year of experience in a community health or Federally Qualified Health Center setting is preferred.
At least 1 year of direct or indirect support of patient care or related experience.
Knowledge, Skills And Abilities
Additional language proficiency highly desired.
Ability to interact positively and build rapport with patients, coworkers and/or external contacts.
Ability to respond to the needs and concerns of the full range of STRIDE’s diverse patient population effectively and sensitively.
Ability to handle sensitive information ethically and responsibly.
Ability to protect the confidentiality of patient, employee, and business information.
Ability to discern information from others in a variety of formats and communicate information to others in a manner that helps them understand instruction.
Ability to work independently in a manner that ensures accuracy and efficiency.
Ability to demonstrate empathy with potential cultural and diversity dynamics.
Ability to utilize advanced customer service skills, including the ability to diffuse upset patients.
Miscellaneous Requirements
COVID-19 Vaccination
Annual Influenza Vaccination
Seniority level
Entry level
Employment type
Other
Job function
Other
Industries
Hospitals and Health Care
Referrals increase your chances of interviewing at STRIDE Community Health Center by 2x