Care Coordinator

JOB REQUIREMENTS: The Care Coordinator will provide interdisciplinarycare coordination services for the medical clinic. Care Coordinationservices will include the daily tasks of increasing patients' access tocare, advocacy of patient needs, community connection to resources,obtaining medical support needs, assisting with crisis resources, andcase management services. Applicants that are empathic, criticalthinkers, work well individually and within a care team, are reliable,organized, and proficient with electronic health record systems willalign well with this position. DUTIES AND RESPONSIBILITIES: General CareCoordination Duties 50% FTE Serves as the primary point of contact forpatients needing assistance navigating healthcare services. Coordinatesappointments, follow-up visits, referrals, labs, imaging, and specialtycare. Ensure timely patient outreach for completion of preventiveservices (annual wellness visits, immunizations, cancer screenings).Monitor the electronic medical record (EMR) and other registries toidentify patients with care gaps (e.g., diabetes mellitus, hypertensionnot controlled, overdue colorectal cancer screening). Provide outreachto patients who are overdue for care or lost to follow-up. Conductpost-discharge calls to support transitions of care after ER visits orhospitalizations. Connect patients to community resources, socialservices, or internal programs (CHWs, physical therapy, dental services,behavioral health). Provides trauma informed resource support andassistance to providers for patients in need of emergency shelter due tohomelessness and resources for food insecurity. Assist with applicationsor referrals for assistance programs as appropriate. Document outreachefforts and patient outcomes in the EHR. Participate inquality-improvement initiatives by providing data, insights, andworkflow suggestions Track patients for follow-up to meet UDS, HEDIS, orvalue-based care quality measures. Responsible for accurate and timelycontributions to all project reporting requirements. Attends andparticipates in other meetings and conferences as appropriate and/oridentified by supervisors. Identify barriers to patient compliance andassist patients in overcoming such barriers. Monitor referrals in EMRfor SDOH needs and assist accordingly. Propose and follow PDSA'srelevant to the above. When necessary and appropriate, coordinate carewith the family of the patient and clinical staff. Diabetes Mellitus(DM) Clinic - 50% of FTE Provides concentrated effort working with theDM Care Team to... For full info follow application link. The Gerald L.Ignace Indian Health Center, Inc. provides equal employmentopportunities to applicants and employees without regard to race, color,religion, sex, sexual orientation, gender identity, national origin,protected veteran status or disability. Equal Opportunityemployer/Veteran/Disabled. American Indian and Veteran Preferenceemployer. APPLICATION INSTRUCTIONS: Apply Online:ipc.us/t/7F34D1A5868843BE Qualified females, minorities, and specialdisabled veterans and other veterans are encouraged to apply.

Created: 2025-12-29