YCHC Patient Services Liaison

Yakutat Tlingit Tribe•Yakutat, AK

6d•$24•Onsite

About The Position

The YCHC Patient Services Liaison is under the direction of the Community Health Educator. This is a clinic-based, non-clinical position responsible for identifying, documenting, coordinating, and monitoring senior-related needs identified within the healthcare setting. This role does not provide clinical care, diagnosis, or treatment. Instead, it functions as a structured communication and coordination role that informs providers, outreach, and Senior Services of Elder needs, barriers to care, and service gaps. The position strengthens integration between clinical services, outreach, and Patient Services by ensuring consistent referral pathways, tracking program utilization, and supporting data-informed planning. The Liaison supports the implementation of the Senior Needs Coordination Program and ensures alignment with YCHC, Tribal, HRSA, IHS, PCMH, and CARF expectations. This position works in coordination with Outreach Program, Senior Services / Senior Center, Primary Care and Behavioral Health Teams, Clinic Administration and Quality Improvement This position requires compliance with Health Center’s compliance standards, including its Standards of Conduct, Compliance Program, and policies and procedures. Such compliance will be an element considered as part of the position’s regular performance evaluation.

Requirements

Knowledge of senior-focused programs, community-based services, tribal resources, and social support systems.
Understanding how housing, transportation, food security, income, and social support affect elder wellbeing.
Working knowledge of Medicaid, Medicare, IHS, VA, and related eligibility and referral processes.
Knowledge of HIPAA requirements and familiarity with HRSA, IHS, PCMH, and CARF compliance standards.
Understanding culturally grounded, Elder-centered, and trauma-informed approaches, particularly within tribal and Indigenous communities.
Case management and care coordination principles.
Social Determinants of Health (SDOH).
Identifying non-clinical elder needs and coordinating appropriate referrals and follow-ups.
Strong communication skills for working with providers, outreach staff, senior services, and community.
Basic computer and EHR proficiency.
Accurately document needs, referrals, and outcomes in EHRs and tracking systems using standardized tools.
Tracking service utilization, identifying trends or gaps, and preparing clear monthly and quarterly reports.
Assisting Elders with applications, forms, and navigating complex systems without crossing into clinical decision-making.
Manage referrals and communication across clinic departments, Senior Services, and external agencies.
Clearly distinguish non-clinical support functions from licensed clinical or social work responsibilities.
Recognize patterns, service gaps, and systemic challenges impacting Elders and elevate them appropriately.
Work collaboratively across departments.
Function autonomously while remaining an effective member of interdisciplinary teams.
Establish respectful, culturally appropriate relationships with Elders, families, and service providers.
Work in a clinic and community-based environment.
Travel locally for outreach or coordination activities as needed.
High school diploma or equivalent.
Experience working with Elders, Tribal communities, rural populations, or healthcare systems.
Possession or ability to readily obtain a valid driver’s license issued by the State of Alaska with a clean driving record.
Must successfully pass a criminal and background check.
Case Management Fundamentals
Care Coordination and Interdisciplinary Teamwork
Social Determinants of Health (SDOH)
Elder Abuse Recognition and Reporting
Overview of Medicaid, Medicare, IHS, and VA systems
Completion of a formal training program or an associate’s degree and one (1) year relevant experience; or, a high school diploma or GED and three (3) years of relevant experience, sufficient to perform the major duties of the position.

Responsibilities

Senior Needs Identification and Coordination
Identify non-clinical senior-related needs based on provider input, screenings, outreach findings, and staff observations.
Document identified needs in the EHR or approved tracking systems.
Initiate and coordinate referrals to Senior Services and relevant community programs.
Support care transitions (e.g., discharge planning, medical travel return, home support needs) in a non-clinical capacity.
Integration with Outreach and Senior Services
Work in close coordination with Outreach staff to align community engagement with clinic-identified needs.
Serve as the primary clinic point of contact for Senior Services regarding Elder-related referrals.
Participate in interdisciplinary meetings, huddles, and coordination discussions as appropriate.
Program Monitoring and Reporting
Monitor Senior Needs Coordination Program usage, referral volume, and service trends.
Track referral outcomes, follow-up status, and service gaps.
Identify emerging needs and systemic barriers affecting Elders.
Prepare monthly and quarterly reports for the Health Educator and Clinic Leadership.
Support quality improvement initiatives related to elder care and social determinants of health (SDOH).
Documentation and Compliance
Maintain accurate, timely documentation in compliance with HIPAA and YCHC policies.
Use standardized templates and forms for referrals and tracking.
Support audit readiness and compliance with HRSA, IHS, PCMH, and CARF standards.
Advocacy and Navigation (Non-Clinical)
Assist Elders in navigating systems such as Medicaid, Medicare, IHS, VA, and community resources.
Support completion of applications and identification processes when tied to documented care needs.
Promote culturally responsive, trauma-informed, and Elder-centered communication.
Professional Practice and Collaboration
Collaborate with providers, behavioral health, nursing, outreach, social services, and tribal programs.
Participate in training, supervision, and professional development activities.
Uphold YCHC and Yakutat Tlingit Tribe values, policies, and ethical standards.
Role Boundaries (Non-Clinical)
The Clinic Senior Services Liaison does NOT:
Provide medical advice, diagnosis, or treatment.
Make clinical decisions or determine medical necessity.
Replace licensed clinical or social work functions.
Must comply with federal laws and regulations as required by the Health Insurance Portability and Accountability Act (HIPAA).
Performs related duties.