Community Health Care Navigator

Sacramento Native American Health Center; Sacramento (CA); On-site; USD 60,174,000 - 65,904,000; Full time

Job summary

Sacramento Native American Health Center seeks a Care Coordinator to support patient engagement, care coordination, and population health initiatives. You will collaborate with providers, care teams, health plans, and community organizations to improve outcomes and reduce barriers to care.

The role includes proactive outreach for preventive care and chronic disease management, navigating social determinants of health, documenting in the EHR, and contributing to quality improvement efforts.

Qualifications

• Experience in ambulatory primary care practice.
• Excellent communication and customer service skills with staff and patients.
• Familiarity with HEDIS, PQRS, and quality metric specifications.
• Experience with Electronic Medical Record systems.
• Knowledge of CPT, ICD, and HCPCS coding.
• Thorough understanding of HIPAA compliance and patient confidentiality standards.

Responsibilities

• Supports panel management and population health workflows for assigned providers and patient populations.
• Assists patients in navigating healthcare services, including referrals and community resources.
• Identifies and addresses barriers to care and adherence to treatment plans.
• Reinforces provider-directed care plans and patient education.
• Coordinates follow-up for chronic conditions or recent hospitalizations.
• Collaborates with providers, nurses, behavioral health staff, health plans, and interdisciplinary teams.
• Participates in daily huddles, care coordination meetings, and quality improvement activities.
• Maintains timely documentation in the EHR.
• Supports performance measures and value-based care initiatives.
• Conducts outreach via telephone, telehealth, in-person visits.
• Maintains knowledge of community resources and partnerships.
• Ensure compliance with HIPAA, OSHA, and applicable policies.
• Perform other duties to support care.
• Participate in internal quality improvement teams.

Skills

Ambulatory care

Communication skills

HEDIS PQRS knowledge

HIPAA compliance

Cultural humility

Care coordination

Education

Certified Community Health Worker (CHW) certification

Tools

EMR systems

Job description

Sacramento Native American Health Center seeks a Care Coordinator to support patient engagement, care coordination, and population health initiatives. You will collaborate with providers, care teams, health plans, and community organizations to improve outcomes and reduce barriers to care.

The role includes proactive outreach for preventive care and chronic disease management, navigating social determinants of health, documenting in the EHR, and contributing to quality improvement efforts.