Health Home Care Coordinator

Care Coordinator – Job Summary

We are seeking a compassionate and organized Care Coordinator to support individuals with complex medical, behavioral health, and social needs. The Care Coordinator works closely with clients, healthcare providers, hospitals, and community partners to develop personalized care plans, improve health outcomes, and connect clients with essential services. This role includes community outreach, in-home visits, care coordination, and ongoing support to help clients achieve their health and wellness goals.

Key Responsibilities

• Conduct comprehensive health assessments and develop individualized Health Action Plans (HAPs).
• Coordinate medical, behavioral health, and social services for clients with complex needs.
• Schedule appointments, facilitate referrals, and ensure timely follow-up with primary care providers and specialists.
• Support hospital and emergency department transitions, including post-discharge follow-up and medication reconciliation.
• Identify gaps in care, remove barriers to services, and connect clients with community resources such as housing, transportation, food, financial assistance, and benefits.
• Perform community outreach, including face-to-face and in-home visits, to engage and support clients.
• Educate clients and caregivers on chronic disease management, preventive care, self-advocacy, and available healthcare resources.
• Collaborate with interdisciplinary teams, healthcare providers, managed care organizations, and community agencies to coordinate care.
• Maintain accurate documentation, patient records, and care plans in compliance with program and regulatory requirements.
• Assist with insurance verification, authorizations, appointment reminders, and other administrative care coordination activities.
• Promote client independence, self-management, and progress toward individualized health goals while respecting client choice and cultural preferences.

Experience & Qualifications:

• Bachelor’s degree in healthcare, behavioral science, social services, or related field; LPN, Peer counsellors. Certified Medical Assistants with an associate degree

• Familiarity with medical terminology and electronic medical record (EMR) systems.

• Strong organizational, communication, and interpersonal skills.

• Proficiency in MS Office (Word, Excel, Outlook).

• Ability to multitask and work in a fast-paced environment.

• Demonstrated knowledge or interest in behavioral and physical health issues.

• Current First Aid & CPR certification or ability to obtain within 90 days of hire.

• Bilingual/bicultural skills are encouraged.

• Experience in social work or related fields is preferred.

• SSN and Work permit required.