Community Health Coordinator

Bluestem Health; Lincoln (NE); On-site; USD 42,000 - 64,000; Full time

Job summary

Bluestem Health is seeking a Community Health Coordinator to help patients and families navigate services, access resources, and adopt healthy behaviors. The CHC supports care management, conducts home visits and health screenings, and advocates for community health needs.

Responsibilities include follow-up with patients, goal setting, coordinating with providers, and maintaining EMR records. Fluency in English/Spanish is preferred, with prior community-based experience valued.

Qualifications

• High School Diploma or equivalent required.
• Nursing Assistant certification required.
• Background in motivational interviewing/health coaching preferred.
• Written and oral fluency in Spanish and English preferred.
• Experience working in a multi-cultural setting preferred.
• Experience in community-based settings 1–2 years preferred.
• Knowledge of medical terminology preferred.
• Basic computer skills; EMR experience preferred.

Responsibilities

• Establish trusting relationships with patients and families; provide general support and encouragement.
• Provide ongoing follow-up, motivational interviewing, and goal setting.
• Follow up with patients via phone, home visits and other settings.
• Help patients set personal health goals and attend appointments.
• Refer patients to community services as appropriate.
• Help patients connect with transportation resources and provide reminders (transportation itself not provided).
• Maintain excellent relations with patients, visitors and staff and communicate Bluestem Health mission.
• Work with medical providers to ensure comprehensive, coordinated care.
• Collaborate with other clinical staff assigned to the same patient.
• Be knowledgeable about community resources relevant to patient needs.
• Provide consistent communication to care team and document patient progress.
• Act as patient advocate and liaison with community service agencies.
• Record patient care management information in EMR and other software within 48 hours of contact.
• Attend staff meetings and trainings; manage assigned caseload.
• May be on-call with prior approval.
• Maintain HIPAA compliance.
• Other duties as assigned.

Skills

Bilingual Spanish & English

Motivational interviewing

Health coaching

Cultural sensitivity

Community outreach

Effective communication

Education

High School Diploma or equivalent

Nursing Assistant certification

EMR/basic computer skills

Tools

EMR system

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. Responsible for establishing trusting relationships with patients and their families while providing general support and encouragement.

2. Provide ongoing follow-up, basic motivational interviewing and goal setting with patients/families.

3. Follow-up with patients via phone calls, home visits and visits to other settings where patients can be found.

4. Help patients set personal health related goals and attend appointments.

5. Provide referrals for services to community agencies, as appropriate.

6. Help patients connect with transportation resources and give appointment reminders in special circumstances. Transporting patients is strictly prohibited.

7. Exhibit excellent working relations with patients, visitors and staff, effectively communicating Bluestem’s Health mission.

8. Work closely with medical provider to help ensure that patients have comprehensive and coordinated care.

9. Work cooperatively with other clinical personnel assigned to the same patient.

10. Be knowledgeable about community resources appropriate to needs of patients/families.

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. Act as a patient advocate and liaison between the patient/family and community service agencies (i.e. schools, DHHS, hospitals, support groups, etc.).

13. Record patient care management information in the EMR and other software no later than 48 hours after patient contact.

14. Attend regular staff meetings, trainings and other meetings, as requested.

15. Manage assigned caseload of patients.

16. May be on-call, as needed, with prior approval.

17. Maintain HIPPA compliance at all times.

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