Community Services Coordinator

UnitedHealth Group•Worcester, MA

5d•$18 - $32•Onsite

About The Position

Under general supervision, the Community Services Coordinator is a vital member of the primary care team who facilitates the care process for at-risk and medically complex patients by addressing gaps in social determinants of health, coordinating accessible plans of care, screening for clinical and social triggers, and tracking adherence. Serving as a liaison among patients and families, primary care teams, specialist physicians, community resources, and interdisciplinary partners, the Community Services Coordinator forms relationships with patients and regularly identifies factors that impact care and treatment plans. The Community Services Coordinator partners closely with clinicians, case management, and social work teams to process referrals and connect patients and families to specialty care, community resources, and social service agencies, addressing social determinants of health such as transportation, disability support, insurance reconciliation, housing, nutrition, and other essential services. The role provides direct patient and family support in accessing and navigating complex medical, behavioral health, and social service systems through in-person, virtual, and telephonic interactions. Additionally, the Community Services Coordinator performs data management and patient outreach for an assigned population, populates standardized clinical and non-clinical information in the electronic medical record to ensure accurate care coordination, and generates reports to support population health and quality initiatives. The Community Services Coordinator ensures clinicians are informed of patient status, may present performance metrics, attend required specialty meetings, and participate in care improvement activities to support optimal health outcomes. The Community Services Coordinator does not provide clinical services or medical advice.

Requirements

1-3+ years of experience in a clinical setting
High School diploma or equivalency certificate (e.g. GED, HiSET, TASC Test) from an accredited institution or governmental unit required
Active Driver’s license and reliable transportation
Knowledge and understanding of medical/healthcare terminology is strongly preferred
Strong interpersonal and communication skills are needed with the ability to interact effectively with patients and medical professionals
Ability to demonstrate a high level of cultural competence and sensitivity to patient needs and concerns.
Ability to engage patients in problem solving
Sound judgment with the ability to work and make decisions in a fast-paced environment
Proficiency with Microsoft Office – especially Word and Excel are required
Excellent telephone skills, strong customer service and ability to build relationships with patients are required

Nice To Haves

Previous training or experience work in healthcare and/or human services preferred
Computer skills includes Electronic medical record (EMR) experience preferred
A bachelor’s degree in related field (typically in healthcare administration, psychology, sociology, Human Services, etc) preferred
Bi-lingual candidates are encouraged to apply

Responsibilities

Contacts patients and families identified via registry or referred by care teams and program staff, to provide guidance, advocacy, and support throughout the care process, including transitions and specialty care needs.
Forms and maintains relationships with patients and families, demonstrating sensitivity to health literacy, preferred language, cultural beliefs, identity, and values impacting care, and staying in touch over time when necessary to ensure gaps are addressed and care plan adherence is in place.
Identifies potential gaps in care planning, condition self-management, and potential presence of barriers to adherence to their plan of care.
Collaborates with primary care teams, case management, nurse case managers, specialists, behavioral health providers, nutrition, social work, insurers, and community partners to coordinate comprehensive care.
Screens for at-risk and medically complex patients for clinical and social triggers (SDoH) that may require intervention and escalates concerns appropriately.
Tracks and supports patient adherence to appointments, laboratory tests, diagnostic studies, referrals, and prescription compliance with goal of closing gaps in preventative health and chronic condition(s).
Conducts high-volume patient outreach via telephone, patient portal messages, mailings, and virtual or in-person encounters to support care plans and follow-up needs.
Processes and coordinates referrals, including specialty care, behavioral health services, and community-based resources.
Assists patients and families in navigating insurance and benefit programs (e.g., MassHealth, Social Security, CommonHealth), as well as community resources addressing transportation, nutrition (WIC/SNAP), housing, utilities, and durable medical equipment.
Provides direct support to patients and families accessing and navigating complex medical, behavioral health, and social service systems.
Documents all outreach, care coordination activities, outcomes, and relevant patient information accurately in the electronic medical record to ensure continuity of care.
Maintains up-to-date community resource lists and reviews population health tools such as registries to identify and address care gaps.
Coordinates and leads regular panel or roster reviews, including chronic disease management and complex care reviews, to support team-based care planning.
Supports Patient Advisory Council meetings and other patient engagement activities, including gathering feedback and assisting with implementation of improvement initiatives.
Maintains collaborative relationships with community organizations, advocacy groups, and stakeholders to enhance patient support and access to services.
Attends required meetings, trainings, and community outreach or educational activities to support program goals and continuous improvement.
Performs other duties as assigned.