Integrated Community Care Coordinator - Routt County

Health Partnership • Steamboat Springs, CO

17d

About The Position

The Integrated Community Care Coordinator helps community members across the Yampa Valley access healthcare, support services, and other resources. The role works directly with Medicaid and Medicare clients to reduce barriers to care, build relationships, and coordinate support among healthcare providers, specialty care teams, and community organizations. Care Coordinators partner with clients to identify goals, navigate complex systems, and develop personalized, goal-oriented care plans supporting health and well-being.

Care Coordinators are based out of the Routt or Moffat offices and are supervised by the Care Coordination Program Manager. The role has no supervisory responsibilities. Work combines office-based, community-based, and remote activity, with regular travel throughout Routt, Moffat, and Rio Blanco counties. Flexible scheduling may be available based on program and client needs. Administrative work takes place in an accessible office environment. Daily activity is described as 80% sitting or standing, including extended keyboard use, and 20% walking, with occasional stooping, bending, reaching, and twisting. The position uses a phone, computer, printer, and copier daily and requires independent regional travel, including during inclement weather.

This is a salaried, non-exempt position eligible for overtime pay for hours worked over 40 in a work week, in accordance with applicable state and federal laws. Compensation is $56,650–$59,000 per year.

Requirements

• High school diploma or equivalent required.
• Ability to communicate effectively with clients, community members, healthcare providers, partner organizations, funders, and government agencies.
• Proficiency with Microsoft Outlook, Word, Excel, Teams, and PowerPoint.
• Strong organizational skills, attention to detail, problem-solving ability, and follow-through.
• Ability to support clients through complex or emotionally challenging situations using active listening, empathy, and motivational interviewing techniques.
• Ability to work independently and collaborate effectively within a team.
• Commitment to inclusiveness, social justice, health equity, and reducing barriers to care.
• Ability to use data to support informed decision-making and collaborative work.
• Comfort navigating ambiguity and identifying practical solutions to challenges.
• Valid Colorado driver’s license, reliable transportation, and willingness to travel throughout the region, including during inclement weather.
• Proof of a valid driver’s license and adequate insurance coverage totaling at least $300,000 per occurrence.

Nice To Haves

• Bachelor’s degree in a related field or equivalent professional experience.
• Fluency in English and Spanish.
• Experience in healthcare, human services, community health, care coordination, or social services.
• Experience working with diverse populations through direct client work and/or case management.

Responsibilities

• Conduct outreach and assess Routt, Moffat, and Rio Blanco County residents enrolled in Medicaid and Medicare.
• Call or text current Medicaid and Medicare members to offer care coordination support.
• Track and monitor client referrals for reporting as requested.
• Complete health and well-being assessments for each client.
• Document client interactions accurately and promptly in the electronic health record and other appropriate systems, including visits, services needed, calls, correspondence, and communications.
• Educate clients and work with them to develop comprehensive, goal-oriented care plans, including identifying barriers to care.
• Build trusting, collaborative relationships with clients, caregivers, healthcare providers, and community partners.
• Meet clients in community settings or residences when appropriate to support their needs.
• Monitor client progress, assess care-plan effectiveness, and adjust support strategies as needed.
• Support clients through complex or emotionally challenging situations using active listening, empathy, and motivational interviewing techniques.
• Connect clients with resources and community partners identified in their care plans.
• Coordinate referrals to healthcare, behavioral health, social service, and community-based resources.
• Collaborate with patients, families, healthcare teams, and community partners to assess and prioritize physical health, mental well-being, financial stability, and social support needs.
• Collaborate with regional healthcare providers, human service agencies, and community organizations.
• Work with the Care Coordination Manager and other Care Coordinators to achieve program deliverables and conduct program evaluations.
• Assess and document care-plan effectiveness and share findings with the Care Coordination Manager.
• Track referrals, interventions, assessments, and program outcomes for reporting and program evaluation.
• Support regional care coordination through data tracking, reporting, and process-improvement initiatives.
• Complete assigned program documentation, evaluations, and reporting requirements.
• Perform work in accordance with organizational safety practices and program standards.
• Engage in cross-departmental collaborative efforts and connect project work to the broader organization.
• Perform other duties as assigned.

Benefits

• Flexible scheduling may be available based on program and client needs.
• Meaningful, community-centered work that directly impacts local residents.
• Collaborative and mission-driven team environment.
• Opportunity to improve access to care and health equity across Northwest Colorado.
• Flexible, relationship-focused work environment.
• Inclusive and supportive workplace culture.
• Eligible for overtime pay for hours worked over 40 in a work week, in accordance with applicable state and federal laws.

What This Job Offers

• Job Type: Full-time
• Education Level: High school or GED