SDOH Care Coordinator IHCI

Community Health Network; Elkhart (IN); Hybrid; USD 42,000 - 54,000; Full time

Job summary

Community Health Network seeks a SDOH Care Coordinator to support patients by addressing social determinants of health through outreach, resource connection, and care coordination. The role engages patients across settings—phone, clinics, home, and hospital—to remove barriers to care and improve access and outcomes.

You'll work with an interdisciplinary team in a primarily remote or hybrid model, ensuring accurate documentation in the EMR and contributing to timely, equitable care for patients

Qualifications

• 2 year / Associate Degree in Human Services, Public and Community Health, Health Services, or Behavioral Health (Required)
• 4 year / Bachelor's Degree in Social Work, Public and Community Health, Behavioral Health, or Health Services (Preferred)
• 2+ years: Experience with Providing SDOH support and community resource connection. (Required)

Responsibilities

• Identify, connect, and support patients in accessing primary care, behavioral health, respite care, and other community-based services.
• Maintain and regularly update a comprehensive inventory of local and regional community resources.
• Apply knowledge of Medicare, Medicaid, and third-party payer guidelines to determine coverage eligibility and align patients with appropriate resources.
• Administer SDOH screenings to identify specific social needs affecting health and well-being.
• Refer and follow up with internal and external resources to support care plans and outcomes.

Skills

Communication skills

Team collaboration

Problem solving

Education

Associate degree in Human Services

Bachelor's degree in Social Work

Job description

Join Community!

Community Health Network was created by our neighbors, for our neighbors. Over 60 years later, “community” is still the heart of our organization. It means providing our neighbors with the best care possible, backed by state-of-the-art technology. It means getting involved in the communities we serve through volunteer opportunities and benefits initiatives. It means ensuring our dedicated caregivers can learn and grow to stay at the top of their fields and to better serve our patients. And above all, it means exceptional care, simply delivered — and we couldn’t do it without you.

Make a Difference

The SDOH Care Coordinator plays a key role in supporting patients by addressing Social Determinants of Health through direct outreach, resource connection, and care coordination. This position engages patients across multiple settings, including by phone, in physician offices, in the home, and in hospital environments, to meet individuals where they are and help remove nonclinical barriers to care. Working within a primarily remote or hybrid model, depending on role requirements, the Care Coordinator collaborates closely with an integrated, interdisciplinary care team to identify social needs, connect patients to appropriate community resources, and support overall care plan success. Through relationship centered engagement and effective coordination, this role contributes to improved access, continuity, and patient outcomes.

Exceptional Skills And Qualifications

Applicants for this position should be able to collaborate with others in a team setting, have excellent communication skills, and a positive attitude toward problem-solving.

• 2 year / Associate Degree in Human Services, Public and Community Health, Health Services, or Behavioral Health (Required)
• 4 year / Bachelor's Degree in Social Work, Public and Community Health, Behavioral Health, or Health Services (Preferred)
• 2+ years: Experience with Providing SDOH support and community resource connection. (Required)

Provide Resource Connection and Navigation

Identify, connect, and support patients in accessing primary care, behavioral health, respite care, and other community based services based on individual needs. Maintain and regularly update a comprehensive inventory of local and regional community resources to ensure timely and equitable access for patients and care partners. Apply a solid working knowledge of Medicare, Medicaid, and third party payer guidelines to determine coverage eligibility and align patients with appropriate community and governmental resources.

Conduct SDOH Screening and Referral Management

Administer Social Determinants of Health (SDOH) screenings to assess and identify specific social needs impacting patient health and well being. Based on screening results, make appropriate referrals to internal and external resources and conduct follow up with patients and providers to monitor progress, address barriers, and support successful connection to services.

Coordinate Care Across the Interdisciplinary Team

Coordinate care by sharing information, resources, and recommendations with referral sources, community agencies, and internal care partners to improve access to services, including primary care. Collaborate closely with the Care Management team to support clinical education needs and care interventions when appropriate. Engage with interdisciplinary team members to ensure alignment on individualized support plans, participate in care conferences for assigned caseloads, and provide insights or assistance to other team members as needed. Ensure accurate, timely, and consistent documentation of required data within the EMR and Care Management platforms.

Engage and Support Patients Throughout the Care Journey

Build trust and rapport with patients to promote engagement, self-efficacy, and active participation in their care. Interact with patients through multiple settings—including phone, physician offices, patient homes, and hospital environments—to meet patients where they are and support care coordination needs. Provide clear education regarding available resources, care plans, and expected next steps, and utilize a variety of outreach strategies tailored to diverse populations to encourage ongoing participation and follow up

Why Community?

At Community Health Network, we build teams that deliver exceptional care through empathy, communication and collaboration. We consider ALL an integral part of the exceptional patient experience. We PRIIDE ourselves on not having employees but Caregivers. Join our Community as we make a difference in your community.