Community Health Coordinator

Bluestem Health•Lincoln, NE

About The Position

The Community Health Coordinator (CHC) helps patients and their families navigate and access community services and other resources, and supports healthy behaviors. The CHC supports providers and staff through integrated care management and community outreach, with the goal of promoting, maintaining, and improving the health of patients and their families. The position provides social support and informal counseling, advocates for individual and community health needs, and delivers services within its scope of practice. Community outreach, including home visits and health screenings, is required.

Requirements

High school diploma or equivalent.
Nursing Assistant certification.
Experience working in a multicultural setting.
Basic computer skills.
Ability to initiate and maintain positive working relationships with Bluestem Health staff and other organizations.
Understanding of the community served and community connectedness.
Good communication skills, including listening well and using language appropriately.
Ability and willingness to provide patients with emotional support, encouragement, and motivation.

Nice To Haves

Background in motivational interviewing or health coaching.
Written and oral fluency in Spanish and English.
At least 1 to 2 years of experience working in a community-based setting.
Knowledge of some medical terminology.
Experience with electronic medical records (EMR).

Responsibilities

Establish trusting relationships with patients and their families while providing general support and encouragement.
Provide ongoing follow-up, basic motivational interviewing, and goal setting with patients and families.
Follow up with patients by phone, through home visits, and in other settings where patients can be found.
Help patients set personal health-related goals and attend appointments.
Refer patients to community agencies for services, as appropriate.
Help patients connect with transportation resources and provide appointment reminders in special circumstances; transporting patients is strictly prohibited.
Maintain excellent working relationships with patients, visitors, and staff, and communicate Bluestem’s Health mission effectively.
Work closely with medical providers to help ensure comprehensive, coordinated patient care.
Cooperate with other clinical personnel assigned to the same patient.
Maintain knowledge of community resources appropriate to patients’ and families’ needs.
Communicate consistently with the care team to evaluate patient and family status, ensuring information and reports clearly describe progress.
Act as a patient advocate and liaison between patients or families and community service agencies, including schools, DHHS, hospitals, and support groups.
Record patient care management information in the EMR and other software within 48 hours of patient contact.
Attend regular staff meetings, trainings, and other meetings as requested.
Manage an assigned caseload of patients.
Be on call as needed, with prior approval.
Maintain HIPAA compliance at all times.
Perform other duties as assigned.