Care Coordinator

SACRAMENTO NATIVE AMERICAN HEALTH CENTER INC•Sacramento, CA

13d•$21 - $23•Onsite

About The Position

The Care Coordinator supports patient engagement, care coordination, population health initiatives, and community-based resource navigation for assigned patient populations. This role works closely with providers, care teams, health plans, and community organizations to improve health outcomes, close care gaps, reduce barriers to care, and support patients in navigating the healthcare system. The Care Coordinator provides proactive outreach and follow-up for preventive care, chronic disease management, transitions of care, and social determinants of health needs while supporting organizational quality and value-based care goals. This position serves as a trusted connection between patients and the healthcare team, helping patients access appropriate medical, behavioral health, and community support services. This role is designed to support California Medi-Cal Community Health Worker (CHW) service requirements and population health initiatives in alignment with organizational and regulatory standards. Role may need to float to other SNAHC locations.

Requirements

Experience in ambulatory primary care practice
Excellent communication and customer service skills with both staff and patients
Familiarity with HEDIS, PQRS, and quality metric specifications
Experience with Electronic Medical Record systems
Knowledge of CPT, ICD, and HCPCS coding
Thorough understanding of HIPAA compliance and patient confidentiality standards

Nice To Haves

Certified Community Health Worker
Experience working with underserved or vulnerable populations preferred.
Knowledge of Medi-Cal, managed care, population health, or community resources preferred.
Bilingual skills highly desirable.
Experience in an FQHC, community clinic, health plan, or care management environment preferred.

Responsibilities

Care Coordination & Case Management
Patient outreach
Care planning
Care transitions
High-risk patient support
Referral coordination
Population Health & Quality
Care gap closure
Registry management
Panel management
HEDIS/UDS/MCAS support
Preventive services
Community & Resource Navigation
SDOH assessment
Community resources
Transportation
Housing
Food access
Benefits navigation
Supports panel management and population health workflows for assigned providers and patient populations.
Assists patients in navigating healthcare services, specialty referrals, behavioral health resources, transportation services, food resources, housing support, and other community-based programs.
Identifies and address barriers impacting patient access to care and adherence to treatment plans.
Reinforces provider-directed care plans, patient education, and self-management goals.
Coordinates follow-up care for patients with chronic conditions, recent hospitalizations, emergency department visits, or identified high-risk needs.
Collaborates with providers, nurses, behavioral health staff, health plans, and interdisciplinary teams to support coordinated patient care.
Participates in daily huddles, care coordination meetings, and quality improvement activities.
Maintains timely and accurate documentation in the electronic health record (EHR) and other population health platforms.
Supports organizational performance goals related to health plan specific measures, HEDIS, UDS, CalAIM, value-based care, and other quality initiatives.
Conducts outreach through telephone, telehealth, in-person visits, and community-based engagement activities as appropriate.
Maintains knowledge of community resources and establish collaborative relationships with community organizations and partner agencies.
Protect patient confidentiality and comply with HIPAA and all applicable organizational policies and procedures.
Ensure compliance with HIPAA, OSHA, SCAR, and all applicable laws and internal policies.
Perform other duties as assigned to support patient care and population health operations.
Participate in internal quality improvement teams.
Works with team members proactively to drive quality improvement initiatives in accordance with the mission and strategic goals for the organization, federal and state laws and regulations, and accreditation standards.
Compliance with all state and federal laws and regulations, as they pertain to position including; HIPAA, sexual harassment, scope of practice, OSHA, etc