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CommuniCare+OLE is seeking a Care Coordinator to serve as the primary contact for patients and families, linking them with internal and external services and addressing social determinants of health. You will support the care team, coordinate referrals, and help patients navigate resources to improve outcomes.
The role emphasizes warm hand-offs, documentation in the EMR, and collaboration with the BH Manager, Care Coordination, at the South Napa Campus.
$29.32 to $35.83/hr (depending on years of care coordination experience)
Monday to Friday, 8am to 5pm (full time)
Care Coordinator
Care Coordination
BH Manager, Care Coordination
South Napa Campus
$29.32 to $35.83/hr (depending on years of care coordination experience)
Monday to Friday, 8am to 5pm (full time)
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NO
Established in 2023, CommuniCare+OLE is the result of a union of two health centers with a deep roots in their respective communities and reputations for providing high-quality primary care to all, regardless of insurance or ability to pay: OLE Health of Napa and Solano Counties and CommuniCare Health Centers of Yolo County. Building on a legacy established by both organizations in 1972, CommuniCare+OLE is a network of federally-qualified health centers with 17 sites across Napa, Solano, and Yolo Counties. It offers comprehensive care, including medical, dental, behavioral health and substance use treatment, nutrition, optometry, pharmacy, care coordination, referrals, and enrollment assistance to more than 70,000 individuals, and no one is turned away due to lack of insurance, immigration status, or ability to pay. Many services are offered outside of its sites, including mobile health, home visiting, and community and school-based programs.
CommuniCare+OLE provides an inclusive workplace that promotes and values diversity and life experience. CommuniCare+OLE encourages people of all backgrounds to apply including, but not limited to, Black, Indigenous Peoples, people of color, immigrants, refugees, women, LGBTQIA+, people with disabilities, veterans, individuals of all ages and religions, and individuals who have been affected by the legal system.
YOU ARE WELCOME HERE. ***The following reflects requirements and essential functions of this position but does not restrict tasks that may be assigned. Essential functions include basic job duties, core elements, or fundamental responsibilities that an employee must perform to hold the position. Employees must be able to perform these essential functions with or without reasonable accommodation (accommodation may be requested). Duties and responsibilities are not all-inclusive, and they may be assigned or reassigned to this job at any time, due to reasonable accommodation or any other reason. ***
Evaluates social determinants of health, identifies barriers to care and addresses/resolves obstacles impeding progress
Processes and closes the loop for community resource referrals
Provides warm hand-offs for urgent and stat medical referrals and collaborates with referral coordinators to ensure medical referrals are processed
Works with direct supervisor and QI department to ensure quality improvement initiatives are met
Meets with each new patient and orients patient and family/caregiver(s) to CommuniCare+OLE
As a member of the care team, participates in huddles, team meetings, and case conferencing as needed
Educates patient and family/caregiver(s) about relevant community resources
Coordinates warm hand-offs for integrated care providers
Provides support to primary care providers by completing forms and other tasks as needed
Provides care management and creates care plans for patients on high-risk registry.
Documents timely and efficiently in the EMR
Care manages and documents as per Enhanced Care Management (ECM) processes, a percentage of patients on the high-risk registry determined by the BH Manager, Care Coordination.
Covers care coordination duties for colleagues who are out of the office
Attends appropriate training courses/webinars and meetings
Gathers and reports data related to aspects of care coordination when needed
Provides feedback for the improvement of Care Coordination processes
Performs other duties as assigned.