Social Determinants of Health Coordinator

Schedule

Monday – Friday (8:00 AM – 5:00 PM) with a 1‑hour lunch.

Compensation

$52,000 – $62,000 a year (based on experience).

Job Summary

This role assists primary care providers, nurses, and care managers with complex situations related to resolving the social determinants of health (SDOH) needs of our members. The SDOH Coordinator supports members by linking them to community resources that meet their SDOH needs through referrals, assistance with completing applications, and follow‑up.

Key Skills

• Maintaining knowledge of community resources.
• Understanding eligibility requirements and application processes for benefits and resources (e.g., health plan benefits, entitlements, SNAP, housing/shelter programs, transportation).
• Identifying the appropriate resource for each member’s unique situation.
• Organizational skills to follow up timely and ensure successful access to resources.

Duties and Responsibilities

• Receive referrals from the Integrated Care Team (ICT) to address members’ SDOH needs identified during routine assessment or requested by the member.
• Assist members with referrals and coordinate services with community resources, including:
  • Housing (voucher programs, halfway houses, shelters)
  • Government benefits (SNAP, phones, transportation)
  • Food and personal/household items (food pantries, soup kitchens, homeless outreach centers, clothing, seasonal drives, winter clothing closets)
  • Utility assistance (LIHEAP)
  • Advocacy (letters of medical necessity for eviction or utility shut‑off notices)
  • Obtaining picture ID and/or birth certificate documents
  • Medication assistance (enrolling patients in medication co‑pay assistance programs)
  • Transportation (health plan eligibility, public transportation/bus passes)
  • Educational and vocational resources
• Update the local Center’s Community Resource Guide as needed.
• Collaborate with ICT on services not covered by the health plan.
• Exhaust all community and health‑plan options before requesting additional funds for SDOH items.
• Work closely with the local Resource Specialist on member fund requests for SDOH expenses not otherwise provided.
• Coordinate with the Behavioral Health team for mental health and substance‑use services and referrals.
• Participate in integrated care team huddles, population health meetings, and ad‑hoc case consultations.
• Follow primary care provider action plans to meet member needs.
• Coordinate with a local licensed behavioral health professional for clinical oversight on referrals requiring assessment or intervention.
• Maintain CPR/BLS certification.
• Coordinate with Community Health Workers (CHW) to meet members’ SDOH needs in the community.
• Communicate with assigned care managers and interdisciplinary team to provide status of barriers, interventions, and referrals.
• Engage members directly in the center, building relationships and connecting them to SDOH resources.
• Meet with members in the community as necessary and engage members telephonically.
• Document all interactions in the electronic health record within required timeliness standards.
• Prioritize tasks to ensure timely completion, discerning urgency and meeting response‑time performance metrics.
• Work with the local Resource Specialist on ordering, distributing, tracking, and reporting the Center’s SDOH inventory of on‑demand items.

Minimum Qualifications

• Bachelor’s degree in public health, social work, human services, or related health‑care field, or equivalent experience.
• At least 3 years of experience serving the needs of complex populations.
• 2 years of experience serving complex populations (e.g., Medicaid, Medicare, uninsured), preferably in a health‑care or social‑services setting.
• Extensive knowledge of local community resources and entitlement/application processes.
• Strong teamwork skills for effective work within an integrated care team.
• Strong written and oral communication skills.
• Strong interpersonal skills to build relationships with staff, members, and community stakeholders.
• Ability to work independently to complete and follow up on assigned tasks.
• Problem‑solving skills.
• Operates a personal motor vehicle; holds an active driver’s license and proof of insurance in the state of practice.
• Passion for addressing health disparities and social needs of low‑income, high‑risk populations of diverse backgrounds, ages, and abilities.
• Proficiency in computer software including Outlook, Word, Excel, PowerPoint.
• Comfortable communicating by video conference and phone.
• Experience with electronic health record documentation (preferred).

Working Conditions

This position operates in a professional office environment and out in the local community. The role routinely uses general office equipment and requires reliable personal transportation, a current driver’s license, and proof of insurance to complete community visits as needed.

Physical Requirements

• Ability to communicate clearly and exchange accurate information constantly.
• Ability to remain stationary for long periods of time.
• Frequent operation of a computer, keyboard, copy/fax machine, phone, and other general office equipment.
• Operates a personal motor vehicle.
• Ability to occasionally move objects up to 20 lb.