Assistant Clinical Care Coordinator (Primary Care Clinic)

FDIHB•Fort Defiance, AZ

About The Position

The Assistant Clinical Care Coordinator develops, implements, and continually evaluates comprehensive care plans with patients, families, and care teams, updating plans to address needs, strengths, and available supports. The role coordinates care across clinics, inpatient services, mental health providers, families, and community agencies; facilitates meetings; and supports timely communication and follow-up with subspecialty and co-management services. The coordinator provides patient-appropriate education, counseling, anticipatory guidance, crisis intervention or referrals, and support for family caregiving. The position also helps patients and families access medical, psychological, developmental, educational, social, and financial services, and serves as a point of contact and advocate for families and community partners, including maintaining a close working relationship with the FDIHB Purchase Referred Care department. The coordinator supports identification and monitoring of patients with chronic care needs, maintains the chronic disease registry, applies case-finding criteria, and develops procedures to facilitate access to public and private programs. The role consults with FDIHB staff, assists with policies and referral procedures for complex chronic care, contributes to quality improvement, and attends to empaneled complex patients’ clinical needs in collaboration with primary care providers and clinical nurses. It also provides community outreach and education, helps develop educational materials, completes required CMS training, and supports compliance with CMS standards. Other duties may be assigned. Applicants must have a valid, unrestricted, insurable driver’s license. A resume and references are required. Degree, transcripts, license, and certifications should be emailed to [email protected]. FDIHB applies Navajo/Indian Employment Preference: qualified enrolled Navajo Nation members receive primary preference, members of other federally recognized tribes receive secondary preference, and other candidates are considered after preference candidates have been fully considered. The posting lists a closing date of Monday, November 9, 2026, at 4:00 p.m. and an hourly range of $29.03–$35.99.

Requirements

At least two years of Nursing Assistant, Medical Assistant, or other health-care-related experience in a clinical, medical/surgical, critical care, or outpatient setting.
Associate of Science degree in Nursing, Social Work, Human Services, or a related field from an accredited program.
Valid American Heart Association Basic Life Support (BLS) certification and ability to maintain it.
Valid, unrestricted license in any U.S. state or territory.
Valid, unrestricted, insurable driver’s license.
Resume and references are required.
Submit degree, transcripts, license, and certifications to [email protected].

Responsibilities

Develop, implement, evaluate, and continually update comprehensive patient care plans with patients, families, and care teams.
Coordinate care across families, clinics, inpatient services, mental health services, and involved agencies.
Facilitate team conferences and meetings, and attend community meetings with families as needed.
Support subspecialty co-management through timely communication, inquiry, follow-up, and integration of information into care plans.
Educate, counsel, and support patients, provide appropriate anticipatory guidance, and intervene or arrange referrals in crises.
Build care relationships and patient-specific skills among families and care teams, and support family caregiving.
Help patients and families access medical, psychological, developmental, educational, social, and financial services and supports.
Identify patients with chronic care needs, maintain the chronic disease registry, and use it to plan and monitor care while applying appropriate inclusion and exclusion criteria.
Understand, catalog, and develop procedures concerning eligibility, referrals, and funding for public and private services and programs.
Serve as a point of contact, advocate, and information resource for families and community partners and payers, including working closely with FDIHB Purchase Referred Care.
Serve as a consultant and resource to FDIHB staff on patient care issues.
Assist in developing and maintaining policies and procedures for care coordination of complex chronic-disease patients, screening, and formal referral processes.
Contribute to quality improvement by helping measure quality and identify, test, refine, and implement practice improvements.
Maintain professional development through seminars, workshops, independent study, and professional affiliations.
Attend to empaneled complex patients’ clinical needs in the clinic or inpatient unit as needed, collaborating with primary care providers and clinical nurses.
Provide community outreach and education about chronic care patients, their needs, and the Chronic Care Model.
Help develop educational materials and provide instruction suited to the target audience using age-specific, developmentally and culturally appropriate learning principles.
Respond to community queries about chronic diseases and related issues.
Complete annual CMS-required training by due dates and support compliance with established CMS standards.
Perform other duties as assigned.