Care Coordinator

General Purpose

As a vital member of the care team, Care Coordinators support the organization’s quality and value-based care efforts through coordination of internal and external services, referral management, and basic health education interventions.

Essential Duties/Position Responsibilities

• Coordinates internal and external services for patients in collaboration with the care team.
• Utilizes evidence-based screening tools to identify and document social determinants of health (SDH) and health-related social needs (HRSN) and provides resources and referrals to internal and external partners best equipped to address identified barriers.
• Knows and maintains the database of community resources available to STRIDE’s patient population.
• Documents and communicates in a “closed loop” fashion with both patient and care team from initial interaction to closure of the episode or completion of goals.
• Conducts patient interaction(s) with respect, collaboration, and confidentiality utilizing basic principles of motivational interviewing when appropriate.
• Provides basic health education using evidence-based educational resources from nationally recognized sources or the Electronic Health Record and refers patients to appropriate internal or external resources for further education and support when indicated.
• Manages internal and external referrals in accordance with organization policies, procedures, and standards including maintenance of the referral partner database, referral processing, follow-up with external agencies and providers to “close the loop”, retrieving and indexing reports.
• Contributes to population health efforts including targeted outreach and scheduling of patients based on specific criteria such as the presence of a chronic condition, wellness visit due, preventative health needs, recent emergency department or hospital visit, or at provider/organization request.
• Follows departmental standard workflows.
• Supports quality improvement activities including those informed by external partners, payors, accreditors, and regulators as assigned.
• Completes all other duties as assigned.

STRIDE Values

• Community: All are welcome at STRIDE - our patients are the center of our work.
• Trust: Our patients feel safe, empowered, and supported.
• Value: We respond to patients' needs by providing effective, affordable care.
• Compassion: We treat patients with kindness, empathy, and dignity.

Education and Experience

• Required: High school diploma or GED.
• Required: Active BLS certification.
• At least 1 year of direct or indirect support of patient care or related experience.
• At least 1 year of experience in a community health or Federally Qualified Health Center setting is preferred.

Knowledge, Skills and Abilities

• Additional language proficiency highly desired.
• Ability to interact positively and build rapport with patients, coworkers and/or external contacts.
• Ability to respond to the needs and concerns of the full range of STRIDE’s diverse patient population effectively and sensitively.
• Ability to handle sensitive information ethically and responsibly.
• Ability to protect the confidentiality of patient, employee, and business information.
• Ability to discern information from others in a variety of formats and communicate information to others in a manner that helps them understand instruction.
• Ability to work independently in a manner that ensures accuracy and efficiency.
• Ability to demonstrate empathy with potential cultural and diversity dynamics.
• Ability to utilize advanced customer service skills, including the ability to diffuse upset patients.

Miscellaneous Requirements

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