Position Summary

The Care Coordinator serves as a crucial advocate for PrimeCare’s patients, providing guidance and support to address social determinants of health and remove barriers to care. By conducting health risk assessments and ensuring emergency room and inpatient follow-ups, the Care Coordinator helps bridge the gap between patients and their primary care providers. This role is an opportunity to make a meaningful impact by connecting patients to vital health and social resources, improving their overall well-being.

Duties and Responsibilities 

• Conduct telehealth risk assessments and connect patients to community resources (e.g., insurance, transportation, childcare, employment, legal aid).
• Follow up with patients’ post-hospital visits, providing education on hospital use and PrimeCare’s clinical options.
• Schedule follow-up medical and behavioral health appointments.
• Educate patients on preventive health measures and the importance of regular primary care visits.
• Facilitate communication among patients, providers, nurses, medical assistants, and external resources.
• Serve as an integral member of the care team by reviewing daily schedules and patient charts to identify gaps in care and patient needs.
• Maintain accurate and timely documentation of patient interactions in PrimeCare’s electronic medical record (EMR) and on care management platforms.
• Conduct population-based outreach to ensure timely follow-ups on vaccinations, screenings, chronic condition management, and prenatal care, as needed.
• Travel between clinic sites, as needed, for in-person patient meetings.
• Availability to work one evening per week or Saturdays.
• Network and collaborate with community-based organizations that offer evidence-based modalities of Assertive Community Treatment (ACT), Community Support Team (CST), and/or psychosocial rehabilitation (PSR) to facilitate patient referrals. 

Required Skills or Abilities 

• Demonstrated ability to collaborate and communicate effectively in a team setting.  
• Ability to maintain effective and professional relationships with patients and other members of the care team.
• Displays high organization skills, with great attention to detail.  
• Adaptability to work in a dynamic health environment. 

Qualifications, Knowledge, Experience, or Licensure

• Bachelor’s degree strongly preferred, or equivalent relevant experience required.
• One (1) to three (3) years of work experience in social services, with community health experience highly preferred.
• Experience working with underserved, transient populations.
• Proficiency in Microsoft Office Suite (Outlook, Word, Excel, PowerPoint).
• Oral and written bilingual fluency in English/Spanish strongly preferred.