Care Coordinator

Here at SNAHC, you are joining a team and company at a time of growth and transformation. You will love being surrounded by people who are as passionate as you are about healthcare and giving back to the community. Please note that individual total compensation for this position will be determined at the Company's sole discretion and the wage range for this role considers a wide range of factors including but not limited to skill sets; experience and training; licensure and certifications; and other business and organizational needs. At SNAHC, it is not typical for an individual to be hired at or near the top of the range for their role and compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current range is $21.00/HR-$23.00/HR.Position Summary:The Care Coordinator supports patient engagement, care coordination, population health initiatives, and community-based resource navigation for assigned patient populations. This role works closely with providers, care teams, health plans, and community organizations to improve health outcomes, close care gaps, reduce barriers to care, and support patients in navigating the healthcare system.The Care Coordinator provides proactive outreach and follow-up for preventive care, chronic disease management, transitions of care, and social determinants of health needs while supporting organizational quality and value-based care goals. This position serves as a trusted connection between patients and the healthcare team, helping patients access appropriate medical, behavioral health, and community support services.This role is designed to support California Medi-Cal Community Health Worker (CHW) service requirements and population health initiatives in alignment with organizational and regulatory standards.*Role may need to float to other SNAHC locationsEssential Functions:Care Coordination & Case ManagementPatient outreachCare planningCare transitionsHigh-risk patient supportReferral coordinationPopulation Health & QualityCare gap closureRegistry managementPanel managementHEDIS/UDS/MCAS supportPreventive servicesCommunity & Resource NavigationSDOH assessmentCommunity resourcesTransportationHousingFood accessBenefits navigationThis role:Supports panel management and population health workflows for assigned providers and patient populations.Assists patients in navigating healthcare services, specialty referrals, behavioral health resources, transportation services, food resources, housing support, and other community-based programs.Identifies and address barriers impacting patient access to care and adherence to treatment plans.Reinforces provider-directed care plans, patient education, and self-management goals.Coordinates follow-up care for patients with chronic conditions, recent hospitalizations, emergency department visits, or identified high-risk needs.Collaborates with providers, nurses, behavioral health staff, health plans, and interdisciplinary teams to support coordinated patient care.Participates in daily huddles, care coordination meetings, and quality improvement activities.Maintains timely and accurate documentation in the electronic health record (EHR) and other population health platforms.Supports organizational performance goals related to health plan specific measures, HEDIS, UDS, CalAIM, value-based care, and other quality initiatives.Conducts outreach through telephone, telehealth, in-person visits, and community-based engagement activities as appropriate.Maintains knowledge of community resources and establish collaborative relationships with community organizations and partner agencies.Protect patient confidentiality and comply with HIPAA and all applicable organizational policies and procedures.Ensure compliance with HIPAA, OSHA, SCAR, and all applicable laws and internal policies.Perform other duties as assigned to support patient care and population health operations.Participate in internal quality improvement teams. Works with team members proactively to drive quality improvement initiatives in accordance with the mission and strategic goals for the organization, federal and state laws and regulations, and accreditation standards.Compliance with all state and federal laws and regulations, as they pertain to position including; HIPAA, sexual harassment, scope of practice, OSHA, etcCompetencies:Patient-centered communicationCultural humility and community engagementCare coordination and follow-throughProblem-solving and resource navigationTeam collaborationOrganization and time managementAdaptability and initiativeDocumentation accuracy and attention to detailMinimum Qualifications:Experience in ambulatory primary care practiceExcellent communication and customer service skills with both staff and patientsFamiliarity with HEDIS, PQRS, and quality metric specificationsExperience with Electronic Medical Record systemsKnowledge of CPT, ICD, and HCPCS codingThorough understanding of HIPAA compliance and patient confidentiality standardsPreferred Qualifications:Certified Community Health WorkerExperience working with underserved or vulnerable populations preferred.Knowledge of Medi-Cal, managed care, population health, or community resources preferred.Bilingual skills highly desirable.Experience in an FQHC, community clinic, health plan, or care management environment preferred.Certification RequirementEmployees hired into this role will be expected to obtain Community Health Worker (CHW) certification within a timeframe established by the organization. The organization will support and cover the cost of the certification process in accordance with organizational guidelines.Please Note: This position may be grant funded. Continued employment is contingent upon renewed or additional funding and may be discontinued at the close of the grant cycle. Grant funding for any position does not impart any contractual right, either expressed or implied, to remain in Sacramento Native American Health Center, Inc.’s employment for a specific period of time. Grant funding does not affect the Sacramento Native American Health Center, Inc.’s status as an “at will” employer. #J-18808-Ljbffr Paycom - ATS