Community Services Coordinator

Optum · Worcester, MA · 6 days ago

OTHR$18–$32/hrFull-time

About the role

The Community Services Coordinator plays a crucial role in improving health outcomes by facilitating the care process for at-risk and medically complex patients. This position involves addressing gaps in social determinants of health, coordinating accessible plans of care, screening for clinical and social triggers, and ensuring patient adherence.

Responsibilities

Contacts patients and families to provide guidance, advocacy, and support throughout the care process, including transitions and specialty care needs.
Forms and maintains relationships with patients and families, demonstrating sensitivity to health literacy, preferred language, cultural beliefs, identity, and values impacting care.
Screens for at-risk and medically complex patients for clinical and social triggers (SDoH) that may require intervention and escalates concerns appropriately.
Collaborates with primary care teams, case management, nurse case managers, specialists, behavioral health providers, nutrition, social work, insurers, and community partners to coordinate comprehensive care.
Tracks and supports patient adherence to appointments, laboratory tests, diagnostic studies, referrals, and prescription compliance with the goal of closing gaps in preventative health and chronic conditions.
Conducts high-volume patient outreach via telephone, patient portal messages, mailings, and virtual or in-person encounters to support care plans and follow-up needs.
Processes and coordinates referrals, including specialty care, behavioral health services, and community-based resources.
Assists patients and families in navigating insurance and benefit programs (e.g., MassHealth, Social Security, CommonHealth), as well as community resources addressing transportation, nutrition (WIC/SNAP), housing, utilities, and durable medical equipment.
Provides direct support to patients and families accessing and navigating complex medical, behavioral health, and social service systems.
Documents all outreach, care coordination activities, outcomes, and relevant patient information accurately in the electronic medical record to ensure continuity of care.
Maintains up-to-date community resource lists and reviews population health tools such as registries to identify and address care gaps.
Coordinates and leads regular panel or roster reviews, including chronic disease management and complex care reviews, to support team-based care planning.
Supports Patient Advisory Council meetings and other patient engagement activities, including gathering feedback and assisting with implementation of improvement initiatives.
Maintains collaborative relationships with community organizations, advocacy groups, and stakeholders to enhance patient support and access to services.
Attends required meetings, trainings, and community outreach or educational activities to support program goals and continuous improvement.

Requirements

High School diploma or equivalency certificate (e.g. GED, HiSET, TASC Test) from an accredited institution or governmental unit required.
1+ years of experience in a clinical setting.
Active Driver's license and reliable transportation.
Previous training or experience working in healthcare and/or human services preferred.
Bachelor's degree in related field (typically in healthcare administration, psychology, sociology, Human Services, etc.) preferred.
Bi-lingual candidates are encouraged to apply.

Skills

Knowledge and understanding of medical/healthcare terminology.
Strong interpersonal and communication skills.
Ability to demonstrate a high level of cultural competence and sensitivity to patient needs and concerns.
Sound judgment with the ability to work and make decisions in a fast-paced environment.
Proficiency with Microsoft Office - especially Word and Excel.
Excellent telephone skills, strong customer service, and ability to build relationships with patients.

Benefits