Integrated Care Navigator

Vibrant-Health-Kc; Kansas City (KS); On-site; USD 27,000 - 39,000; Full time

Job summary

Vibrant Health Kansas City is seeking an Integrated Care Coordinator to support a team-based care model within a PCMH at an FQHC. This role focuses on facilitating seamless patient care, tracking metrics with Azara DRVS, and closing care gaps through coordinated outreach and linkages to community resources.

The ideal candidate is a Medical Assistant or Community Health Worker with strong interpersonal skills, experience with EHRs, and the ability to travel to different sites to support patient

Qualifications

• Experience in a team-based care model, PCMH, or FQHC setting.
• Proficient with Microsoft Office (Word & Excel).
• Strong interpersonal and communication skills with diverse populations.
• Knowledge of care coordination, chronic disease management, and community resources.
• Proficient in EHR and patient management systems.
• Excellent organizational skills and ability to manage multiple tasks in a dynamic environment.
• Developed rapport with patients, families, community, and healthcare staff.
• Professional and respectful demeanor; strong teamwork and collaboration.
• Understanding of cultural diversity; culturally sensitive in interactions.
• Ability to travel to all parts of the facility and throughout the community.

Responsibilities

• Review care plans, outstanding orders, tests, referrals, and care gaps before visits.
• Coordinate with care team to complete documentation, labs, and screenings.
• Identify and address barriers to care including transportation and scheduling.
• Use Social Determinants of Health tool to guide interventions.
• Participate in daily care team huddles for upcoming visits.
• Conduct post-visit follow-up to ensure plan of care.
• Monitor progress and connect patients to resources or programs.
• Organize care activities across the continuum and link to resources.
• Track patient metrics and risk with Azara DRVS.
• Build relationships with community organizations to improve access to resources.
• Serve as liaison between patients and care team; ensure open communication.
• Provide culturally competent outreach to empower patient engagement.
• Close care gaps by outreach for screenings, vaccines, and follow-ups.
• Collaborate with team to ensure well-coordinated care.
• Participate in meetings to discuss patient needs and barriers.
• Support quality improvement by identifying opportunities to improve outcomes.
• Track open orders to completion.
• Document all patient interactions in the EHR.
• Report on engagement, coordination, and quality metrics; advance Vibrant Health’s mission.
• Adhere to organizational policies and procedures.

Skills

Team-based care experience

MS Office (Word & Excel)

Interpersonal skills

EHR familiarity

Organizational skills

Cultural sensitivity

Travel ability

Bilingual English and Spanish

Education

Medical Assistant Certification

Tools

Azara DRVS

Job description

Vibrant Health Kansas City is seeking an Integrated Care Coordinator to support a team-based care model within a PCMH at an FQHC. This role focuses on facilitating seamless patient care, tracking metrics with Azara DRVS, and closing care gaps through coordinated outreach and linkages to community resources.

The ideal candidate is a Medical Assistant or Community Health Worker with strong interpersonal skills, experience with EHRs, and the ability to travel to different sites to support patient