COMMUNITY HEALTH COORDINATOR

Community Health Coordinator

Community Health Coordinator

FLSA Status: Non-Exempt

Encompass Community Supports, formerly known as Rappahannock Rapidan Community Services (RRCS) is hiring a Community Health Coordinator. Encompass Community Supports is a Virginia State community services organization that improves the quality of life in Culpeper, Fauquier, Madison, Orange, and Rappahannock Counties by providing comprehensive mental health, substance use, developmental disability, housing, children’s, and aging services. As an organization of almost 400 employees and more than 80 programs, we lead with integrity and excellence and embrace collaboration, accountability, and innovation to respond to the ever-changing needs of our community.
Our non-profit organization qualifies for the Public Service Loan Forgiveness (PSLF) program, allowing eligible employees to potentially receive student loan forgiveness. ECS is also a registered site for the National Health Service Corps (NHSC) Loan Repayment plan.

Our benefits are highly competitive and include:

• Low employee cost Medical, Dental and Vision Insurances
• 13 paid holidays annually
• 17 PTO days
• Enrollment in VA State pension and retirement plan
• Employee training and educational opportunities
• Paid Life Insurance
• Health Savings Plan
• Flexible Savings Plan
• Employee Assistance Program

At Encompass Community Supports, our full-time employees work 37.5 hours weekly.

Our Community Health Coordinator provides healthcare/MCO specific customer service by contacting health care Members, completing assessments, identifying, and providing community resources and connecting Members with other providers and community services. This position is a community-based role. Member home visits may be required based on Member needs. Flexible work hours may be required, to include some evenings and/or weekends, to ensure Member engagement. This position reports to the Health & Caregiver Support Services Mgr. All work is performed under regular supervision.

ESSENTIAL FUNCTIONS:

• Collaborate with Community Transitions Program to obtain information on appropriate individuals for care transitions services and carry out daily referral process.
• Conducts timely telephonic hospital visits providing information and guidance to the admitted individual and/or family for acceptance of the care transitions program. Serves as a bridge between the individual and/or family and the assigned Field Coach.
• Conducts telephonic home visit assessments/ screenings and conducts supportive follow up telephonic supports with members within the guidelines of the Care Transitions Program.
• Conducts telephonic hospital visits to those individuals readmitted and previously coached to understand reasons/cause for the readmission.
• Prioritize referrals and activities according to intensity, need, and required follow-up. Serves as a guide to the individual, coaching the individual in addressing critical issues and self-management tasks. Refers and/or establishes access to available supportive services/resources.
• Provides information and guidance to the individual and/or family for an effective care transition, provides guidance to improve self-management skills and enhanced individual/patient communication. Serves as a bridge between professional staff in a care setting and the individual and/or family.
• Reports all individual declines to appropriate clinical staff, case management, or care coordinator for follow-up.
• Evaluates aspects of each individual’s condition, diagnoses, medications and support systems to develop an individualized plan, which will lead to a successful outcome in medication self-management, use of a personal health record, appropriate primary care and specialist follow-up and knowledge of red flags.
• Maintains accurate and timely documentation on each referred individual as well as readmitted individuals in database system including complete and concise journal entry notes.
• Maintains weekly / monthly goals and provides daily reports on completed work to establish productivity.
• Performs other duties as assigned.

KNOWLEDGE, SKILLS AND ABILITIES:

• Knowledge of health care industry, caregiving, chronic disease management.
• Knowledge of a wide variant of community resources.
• Knowledge and appreciation of cultural diversity and low literacy issues in care provision.
• Excellent verbal and written communication skills.
• Ability to work in and away from the office.
• Ability to work methodically and patiently with limited resources and support.
• Ability and willingness to self-motivate, prioritize, and be willing to change processes to improve effectiveness/efficiency.
• Ability to work independently while collaborating with other team members.
• Ability to work with individual/families of all ages.
• Knowledge of MS Office, to include Word and Excel.

EDUCATION AND EXPERIENCE:

• High school diploma or equivalent.
• At least 2 years of experience and/or education in Healthcare or Social Services.

SPECIAL REQUIREMENTS:

• Valid Virginia driver’s license.
• Attends trainings and maintains certifications as required by the Agency and regulatory guidelines.
• Employment with Encompass Community Supports is contingent upon the successful completion of our background check process (criminal, DMV, education, drug screening, reference check, DSS, OIG and SAM).

Encompass Community Supports is an Equal Opportunity Employer

Posting Start : 03/19/2026