Primary Accountability
The Care Coordinator coordinates the provision of patient care within the Health Home Program (HHP) to ensure the patients’ care is continuous and integrated amongst service providers, as well as supports the Care Coordinator Manager in the implementation of the HHP. There will be responsibility for the navigation of the patient’s health, behavioral health, social systems, community resources, and housing transitions. There will be collaboration with patients and their family members, health-care team members, and outside organizations to reduce or eliminate barriers to care.
Description of Primary Responsibilities
- Support patient centered, continuous and consistent care, ensuring that an assigned Home Health Program (HHP) patient receives access to needed services identified through the assessment process.
- Coordinating, maintaining and servicing panels of patients with special service needs, as determined by the Health Home Program and stratification process.
- Working with the patient to implement their Health Action Plan (HAP).
- Assisting the patient in navigating health, behavioral health, and social services systems, including housing and transportation.
- Sharing options with the patient for accessing care and providing information regarding care planning.
- Identifying barriers to the patient’s treatment.
- Monitoring and supporting treatment adherence (including medication management).
- Assisting in attainment of the patient’s goals as described in the HAP.
- Encouraging the patient’s decision making and continued participation in HHP.
- Accompanying patient’s to appointments as needed.
- Monitoring referrals, coordination, and follow ups to ensure needed services and supports are offered and accessed.
- Sharing information with all involved parties to monitor the patient’s conditions, health status, care planning, medications usages and side effects.
- Creating and promoting linkages to other services and supports.
- Helping facilitate communication and understanding between HHP patients and healthcare providers.
- Provide health promotion services similar to the role of a health educator, such as providing training materials and teaching self-management skills pertaining to the patient’s goals identified in the Health Action Plan (HAP) as part of the HHP.
- Encouraging and supporting health education for the patient and family/support persons.
- Assessing the patient’s and family/support persons’ understanding of the patient’s health condition and motivation to engage in self‐management.
- Coaching patient’s and family/support persons about chronic conditions and ways to manage health conditions based on the member’s preferences.
- Linking the patient to resources for: smoking cessation, management of chronic conditions, self‐help recovery resources, and other services based on patient needs and preferences.
- Using evidence‐based practices, such as motivational interviewing, to engage and help the patient participate in and manage their care.
- Utilizing trauma‐informed care practices.
- Provide Individual, Family and Community Support Services
- Assessing the strengths and needs of the patient and family/support persons.
- Linking the patient and family/support persons to peer supports and/or community based groups to educate, motivate and improve self‐management.
- Connecting the patient to self‐care programs to help increase their understanding of their conditions and care plan.
- Promoting engagement of the patient and family/support persons in self‐management and decision making.
- Determining when patient and family/support persons are ready to receive and act upon information provided and assist them with making informed choices.
- Advocating for the patient and family/support persons to identify and obtain needed resources (e.g. transportation) that support their ability to meet their health goals.
- Accompanying the patient to clinical appointments, when necessary.
- Identifying barriers to improving the patient’s adherence to treatment and medication management.
- The Care Coordinator has a role as a housing navigator, such as assisting patients with housing transition services, individual housing and tenancy sustaining services.
- Conducting a tenant screening and housing assessment plan.
- Developing a housing support plan which includes prevention and interventions when housing is jeopardized.
- Coaching on the roles, rights and responsibilities of the tenant and landlord, lease compliance and household management.
- Foster relationships with housing agencies to explore independent housing options and assist patient with available temporary and permanent housing.
- Follow safety plan department work instructions to ensure the safety of staff and patients in the community during outreach activities.
- Complete Annual Health and Safety training yearly.
- Provide comprehensive transitional care
- Bringing to the attention of a Clinical Consultant such as a nurse or medical provider any issues regarding medication information and reconciliation.
- Planning timely scheduling of follow‐up appointments with recommended outpatient providers and/or community partners.
- Collaborating, communicating, and coordinating with all involved parties.
- Easing the patient’s transition by addressing their understanding of rehabilitation activities, self‐management activities, and medication management.
- Planning appropriate care and/or place to stay post‐discharge, including temporary housing or stable housing and social services.
- Arranging transportation for transitional care, including to medical appointments.
- Developing and facilitating the patient’s transition plan.
- Consults with Clinical Consultant, such as a nurse regarding prevention and tracking of avoidable admissions and readmissions which could trigger a re-evaluation of the HAP.
- Providing transition support to permanent housing.
- Responsible to support the Care Coordinator Supervisor in the implementation of Health Home Program initiatives, curriculum and objectives.
- Supports Care Coordinator Supervisor in the collection of data and reporting.
- Completes necessary reporting and documentation associated with HHP per organizational and regulatory requirements.
- Care Coordinator interfaces with patients and other stakeholders through a variety of mechanisms, including, but not limited to:
- Individual, face-to-face contacts through both appointment and warm hand-off contacts;
- Telephone and other electronically mediated contacts; and
- Contact outside of FHCN Health Centers to provide linkages to appropriate community resources based upon the patients’ identified needs and goals through the Health Action Plan. This could be a mobile unit for example.
- During contacts with health-care team members at FHCN and from other organizations, Care Coordinators reduce barriers to care in a number of ways including but not limited to:
- Preparing, printing and distributing the information necessary for care teams to engaging in Pre-visit Huddles.
- Maintaining regular communication with care team providers on patient care plan goals and progress.
- Facilitating regular communication between patient and other health-care team members both inside and outside FHCN.
- Providing staff training and education sessions necessary to implement health education services.
- Participates in meetings and trainings as necessary to facilitate the above duties, including those geared toward implementing evaluation tools that determine the effectiveness of Care Coordinator functions.
- Responsible for adhering to the Attendance and Absenteeism Policy, recognizing that regular attendance is considered an essential function of all FHCN positions. Absenteeism is not being at work or failing to attend a paid workshop, training, or event unless the absence is protected by law.
- Ability to present to and work at any FHCN location, both at the beginning of a shift or during a shift, based on business need.
- Performs other duties as assigned.
Description of Primary Attributes
Professional & Technical Knowledge:
Effective June 1, 2026, all individuals hired into the role must:
- Possesses proficiency in written and verbal communication, basic mathematics, computer applications, and technical systems frequently acquired through one of the following:
- Completion of an Bachelor’s Degree program with a recognized major and a minimum cumulative GPA of 2.5 is preferred; or
- A combination of relevant experience and proof of completion of high school with a minimum overall GPA of 2.5 or completion of General Educational Development (GED) with a minimum overall score of 162.5.
- If an individual has completed a degree at a higher level than required by the role and had a stronger GPA in that program, they may provide proof of GPA from that degree in lieu of the high school diploma.
- Job duties require two years of experience, knowledge, and training in the field of social work, nursing, health sciences, health education, or a related field; or be a paraprofessional with more than 7 years of directly related progressive work experience.
Technical Skills:
- Ability to prepare more complex documents in Microsoft Word, including creating tables, charts, graphs and other elements.
- Ability to use Microsoft Excel to review and compile data, including the use of formulas, functions, lookup tables and other standard spreadsheet elements.
- Ability to create basic presentations in Microsoft PowerPoint.
Licenses & Certifications: None required.
Communications Skills:
- Job duties require the compilation of information prepared in effective written form, including correspondence, reports, articles or other documentation.
- Effectively conveys technical information to non-technical audiences.
Physical Demands: The physical demands described here in this job description are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this position, the employee is regularly required to sit and use repetitive hand movement to type and grasp. The employee is frequently required to stand and walk; and must occasionally lift and/or move up to 20 pounds.
Pay Scale:
Min Hourly Rate: $21.99
Max Hourly Rate: $30.35
