Chronic Care Navigator

Northshore Health Centers; Hammond (IN); On-site; USD 42,000 - 64,000; Full time

Job summary

Northshore Health Centers in Hammond, IN is seeking a Care Coordinator to join the ambulatory care team. The role focuses on coordinating care for patients with chronic conditions, promoting preventive health, and supporting healthy behaviors.

You will work with the medical provider, psychiatric consultant, and primary care team to develop individualized care plans, monitor progress, and ensure timely documentation in the electronic health record.

Qualifications

• Minimum education per Indiana/HRSA is required.
• 1 year of care coordination experience.
• Community Health Worker Certification within 1 year of hire.
• Valid CPR certification.

Responsibilities

• Coordinate care plans with patients and care team.
• Identify social determinants of health and set SMART goals.
• Educate patients on proper ER use and alternatives.
• Follow up on transitions of care within 72 hours of discharge.
• Document in the EHR and manage referrals.

Skills

Communication skills

Interpersonal skills

Problem solving

Time management

Attention to detail

Microsoft Office

Education

Indiana/HRSA education requirement

Community Health Worker Certification

Tools

Electronic Health Records (EHR)

Job description

Northshore Health Centers in Hammond, IN is seeking a Care Coordinator to join the ambulatory care team. The role focuses on coordinating care for patients with chronic conditions, promoting preventive health, and supporting healthy behaviors.

You will work with the medical provider, psychiatric consultant, and primary care team to develop individualized care plans, monitor progress, and ensure timely documentation in the electronic health record.