Community Care Coordinator - PRN - (Flagstaff/Coconino County)

Job Description

Job Description

Adobe Population Health ( APH ) is a women-owned health solutions company founded in 2018 and committed to positively impacting the lives we touch .

The company has a culture of inclusivity and human kindness, based in Phoenix, AZ, with satellite locations in multiple states. APH has been recognized as one of “ America's Fastest-Growing Private Companies ” by Inc. 5000 and has earned a " Best Places to Work " award from the Phoenix Business Journal consecutive times.

APH offers customized programs for insurance groups, providers, hospitals, and families, which include case management, in-home/in-clinic wellness assessments, preventative care, transitional care, and social work services. As one of the country's few fully integrated healthcare providers, APH provides top-notch medical services with various service lines. The company is expanding and looking for individuals who want to make a difference and help those in need.

POSITION PURPOSE

The Community Care Coordinator is responsible for providing comprehensive care coordination and management services to clients within an assigned territory.

This role combines field-based care coordination with supervisory responsibilities, focusing on enhancing client outcomes through behavioral, physical, and social interventions. As a CCC, you will oversee case management activities, ensure compliance with organizational policies, and foster positive relationships with clients, caregivers, providers, and team members.  Additionally, you collaborate with healthcare providers, social services, and community organizations to identify and address barriers to health and well-being. The ideal candidate will be passionate about community engagement and equity, and skilled in connecting individuals with appropriate resources that improve their health outcomes.

This position requires travel to Flagstaff, around Coconino County, and surrounding areas to provide in-home support to our members.

PRN EMPLOYMENT STATUS

This is a Per Diem (PRN) position and is scheduled on an “as-needed” basis to support operational staffing needs. PRN employees may be utilized to cover planned and unplanned absences including call-offs, vacations, extended leave, and vacant positions. Adobe Population Health is not obligated to offer shifts, and PRN employees are not guaranteed consistent scheduling beyond program participation requirements .

DUTIES & RESPONSIBILITIES

Resource Sharing and Care Coordination

• Provide field-based care coordination to address behavioral, physical, and social needs of assigned clients, aiming to reduce medical costs and improve quality of life. 
• Assess the social, financial, and health needs of individuals and families within the community.
• Connect clients with appropriate services, including housing assistance, food security programs, healthcare services, transportation, and mental health resources.
• Develop and implement individualized care plans in collaboration with clients, ensuring that their unique needs are addressed.
• Provide ongoing support to ensure clients' needs are met, including follow-ups and reassessments.
• Advocate on behalf of clients to ensure they receive timely access to services and resources.

Health Education and Support

• Offer education on physical health, illnesses, treatments, dietary concerns, stress management, and safe medicine use.
• Provide emotional support to clients and manage their overall well-being. 
• Support clients in developing self-care strategies and accessing preventive health services.
• Encourage clients to actively engage in their health and well-being through empowerment and education.

Community Outreach and Engagement

• Conduct home safety evaluations and monitor client progress through regular home visits.
• Connect clients with appropriate community services and resources.
• Build and maintain strong relationships with local community organizations, healthcare providers, and government agencies to ensure access to a wide range of resources.
• Participate in outreach efforts to identify individuals and families in need, particularly in underserved or marginalized communities.
• Represent the organization at community events, health fairs, and workshops to promote services and educate the public about available resources.
• Identify trends and emerging needs within the community to inform organizational planning and service delivery.

Data Collection and Record Keeping

• Maintain accurate records of care coordination in the Electronic Medical Record (EMR) system and ensure compliance with HIPAA regulations. 
• Document interactions, care plans, and outcomes in accordance with organizational policies and confidentiality guidelines.
• Track and report on the effectiveness of referrals and interventions to help identify gaps in services or areas for improvement.
• Maintain accurate records of client information and provide timely reports to supervisors and funding agencies as required.
• Participate in program evaluation and quality improvement initiatives.

Policy and Procedure Compliance

• Ensure adherence to Adobe policies and procedures, and assist in developing and updating company programs, policies, and procedures as needed. 

Relationship Building

• Develop and maintain positive relationships with case managers, providers, administration, and other stakeholders. 

Travel and Meetings

• Travel to assigned territories for training, meetings, and as requested by upper management. Attend all applicable facility and management meetings. 

Other Duties

• Completes other duties and responsibilities as assigned.

PRN Coverage Expectations

• Maintain availability for a minimum of one (1) eight-hour shift per week.
• Work a minimum of four (4) shifts per month to remain active in the PRN Staffing Program.
• Respond and assist with staffing requests at least three (3) out of every four (4) times contacted when reasonably available.
• Report to assigned shifts at scheduled start times or within two (2) hours when covering unplanned absences.
• Accept assignments within designated service areas as directed by leadership.
• Notify management in advance of any known periods of unavailability following company policy.

SKILLS & QUALIFICATIONS

• Four to six years of related experience and/or training, or an equivalent combination of education and experience.
• Medical experience strongly preferred.
• Experience working with diverse populations, including marginalized, low-income, and underserved communities.
• Must have the willingness to drive with a clean driving record.
• Reliable transportation.
• Clean driving record.
• Excellent communication skills, both verbal and written.
• Requires problem-solving and decision-making.
• Must be able to work in a self-directed environment.
• Identify and resolve problems in efficient and effective ways.
• Takes personal responsibility for the quality and timeliness of work and achieves results with little oversight.
• Adapts to changing business needs, conditions, and work responsibilities
• Proficiency in Microsoft Office Suite.
• Knowledge of confidentiality and data protection regulations, especially in relation to health information (e.g., HIPAA compliance).
• Bilingual (Spanish/English) preferred. 

EDUCATION, LICENSES, & CERTIFICATIONS

• Associate’s degree in Social Work, Sociology, Psychology, Counseling, or a related field required, OR active LPN/RN licensure, EMT, or Paramedic certification; Bachelor’s degree preferred.
• Current BLS certification and annual TB testing required. 
• Current and clear driver’s license.

COMPENSATION & BENEFITS (PRN)

PRN employees are compensated at a premium hourly rate and are not eligible for benefits including but not limited to paid time off, holiday pay, bereavement leave, medical, dental, vision, life insurance, or disability insurance. Workers’ Compensation coverage is provided in accordance with state and federal regulations. PRN employees are not eligible for annual salary adjustments.

CHARACTER & COMPETENCIES

• Diversity - Demonstrates knowledge of EEO policy; Shows respect and sensitivity for cultural differences; Educates others on the value of diversity; Promotes a harassment-free environment; Builds a diverse workforce.
• Ethics - Treats people with respect; Keeps commitments; Inspires the trust of others; Works with integrity and ethics; Upholds organizational values.
• Adaptability - Adapts to changes in the work environment; Manages competing demands; Changes approach or method to best fit the situation; Able to deal with frequent change, delays, or unexpected events.
• Customer Service - Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments.
• Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things.
• Judgement - Displays willingness to make decisions; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions.
• Problem-Solving - Identifies and resolves problems promptly; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem-solving situations; Uses reason even when dealing with emotional topics.
• Professionalism - Tactfully approaches others; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.
• Teamwork - Balances team and individual responsibilities; Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; Able to build morale and group commitments to goals and objectives; Supports everyone's efforts to succeed.

PHYSICAL DEMANDS & WORK ENVIRONMENT

• This position involves a combination of office-based work and fieldwork within the community.
• Travel will be required to attend meetings, conduct home visits, or participate in community events.
• Must be able to frequently drive long distances, which may require a two-hour radius of your designated county (travel time is paid and mileage reimbursement is available).

• Occasionally required to stand.
• Occasionally required to walk.
• Continually required to sit.
• Occasionally required to climb, balance, bend, stoop, kneel, or crawl.
• Continually required to talk or hear.
• While performing the duties of this job, the noise level in the work environment is usually moderate.

• Must be comfortable with working in a variety of conditions, including members’ homes, physicians’ offices, cold conditions, and hot conditions.

• The employee may occasionally lift and /or move more than 30 pounds.

• Must be able to physically perform the essential duties of the position which include lifting 30 lbs., transporting materials, stooping, kneeling, crouching, reaching, use of hands, balancing, walking, standing, talking, hearing, and typing.

EQUAL EMPLOYMENT OPPORTUNITY

APH is an Equal Opportunity Employer where all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.