Community Health Coordinator

Causecollectivelincoln; Lincoln (NE); On-site; USD 42,000 - 56,000; Full time

Job summary

Bluestem Health is seeking a Community Health Coordinator (CHC) to help patients navigate and access community services, support care management, and promote healthy behaviors. The CHC will perform home visits and health screenings, advocate for community health needs, and collaborate with providers to ensure coordinated care for diverse patient groups.

The role emphasizes social support, communication with care teams, and ongoing follow-up to help patients achieve personal health goals.

Qualifications

• High School Diploma or equivalent is required.
• Nursing Assistant certification is required.
• Experience with motivational interviewing/health coaching preferred.
• Written and oral fluency in Spanish and English preferred.
• Experience working in a multi-cultural setting is preferred.

Responsibilities

• Establish trusting relationships with patients and families and provide general support.
• Provide follow-up, motivational interviewing and goal setting.
• Follow-up with patients via phone, home visits, and in other settings.
• Help patients set health goals and attend appointments.
• Provide referrals to community agencies as appropriate.
• Assist patients with transportation resources and remind about appointments where needed (transporation themselves not allowed).
• Maintain HIPAA compliance and document patient information in EMR within 48 hours of contact.
• Coordinate with care team to ensure comprehensive and coordinated care.

Skills

Motivational interviewing

Health coaching

Bilingual English/Spanish

Multicultural experience

Clear communication

Education

High School Diploma or equivalent

Nursing Assistant certification

Tools

EMR systems

Job description

Description

The Community Health Coordinator (CHC) will be responsible for helping patients and their families to navigate and access community services, other resources, and adopt healthy behaviors. The CHC supports providers and the support staff through an integrated approach to care management and community outreach. As a priority, activities will promote, maintain, and improve the health of patients and their family. The CHC will provide social support and informal counseling, advocate for individuals and community health needs, and provide services within scope of practice. Community outreach, such as home visits and health screenings will be required.

1. 1. Responsible for establishing trusting relationships with patients and their families while providing general support and encouragement.
2. 2. Provide ongoing follow-up, basic motivational interviewing and goal setting with patients/families.
3. 3. Follow-up with patients via phone calls, home visits and visits to other settings where patients can be found.
4. 4. Help patients set personal health related goals and attend appointments.
5. 5. Provide referrals for services to community agencies, as appropriate.
6. 6. Help patients connect with transportation resources and give appointment reminders in special circumstances. Transporting patients is strictly prohibited.
7. 7. Exhibit excellent working relations with patients, visitors and staff, effectively communicating Bluestem’s Health mission.
8. 8. Work closely with medical provider to help ensure that patients have comprehensive and coordinated care.
9. 9. Work cooperatively with other clinical personnel assigned to the same patient.
10. 10. Be knowledgeable about community resources appropriate to needs of patients/families.
11. 11. Be responsible for providing consistent communication to the care team to evaluate patient/family status, ensuring that provided information, and reports clearly describe progress
12. 12. Act as a patient advocate and liaison between the patient/family and community service agencies (i.e. schools, DHHS, hospitals, support groups, etc.).
13. 13. Record patient care management information in the EMR and other software no later than 48 hours after patient contact.
14. 14. Attend regular staff meetings, trainings and other meetings, as requested.
15. 15. Manage assigned caseload of patients.
16. 16. May be on-call, as needed, with prior approval.
17. 17. Maintain HIPPA compliance at all times.
18. 18. Other duties as assigned.

Requirements

• · High School Diploma or its equivalent, required.
• · Nursing Assistant certification, required.
• · Background in motivational interviewing/health coaching preferred.
• · Written and oral fluency in Spanish and English is preferred.
• · Experience working in a multi-cultural setting.
• · Experience working in a community-based setting for at least 1 to 2 years preferred.
• · Knowledge of some medical terminology preferred.
• · Basic computer skills required, electronic medical record (EMR) experience preferred.
• · Ability to initiate and maintain positive working relationships with Bluestem Health staff and other organizations.
• · Understand the community served, community connectedness.
• · Good communication skills, such as listening well, and using language appropriately.
• · Ability and willingness to provide emotional support, encouragement and motivation to patients