Job Description
Job Description
Position Summary
The Outreach Care Coordinator acts as a central point of contact for patients, coordinating their healthcare needs at the level of a Certified Medical / Clinical Professional. This role combines direct patient care, care coordination, and community outreach to inform about access to services, education, manage and improve patient outcomes. The Outreach Care Coordinator works closely with healthcare providers, specialists, and community resources to improve access to care, close care gaps, improve clinical outcomes, and support patients in accessing both medical and social services. This position actively contributes to value-based care initiatives , focusing on patient health risk assessments, addressing social determinants of health (SDOH), and engaging in newly assigned outreach efforts.
Essential Duties and Responsibilities
Patient Assessment & Health Risk Assessments
- Conduct and document comprehensive health risk assessments as part of the value-based care initiative to identify patient risk factors, chronic conditions, and opportunities for intervention.
- Use clinical expertise to identify high-risk patients and assess potential barriers to care, including social determinants of health (SDOH), mental health needs, and lifestyle factors.
- Review care plans and value-based care goals, working to improve patient outcomes while reducing unnecessary healthcare utilization.
Care Coordination
Coordinate with primary care providers, specialists, and other healthcare team members to facilitate care that is aligned with value-based care objectives .Assist in obtaining orders, referrals, diagnostic results, and consultation reports to ensure care gaps are closed and clinical outcomes are optimized.Maintain a current resource list and address SDOH factors such as housing, transportation, and food security, by referring patients to community-based resources that can address non-clinical barriers to health.Make patient appointments with FCHC primary care providers.Use EHR to track patient progress, document health assessments, and monitor care plans, ensuring that both clinical needs and SDOH are addressed.Patient Education & Value-Based Care Focus
Educate patients about their health risks, the importance of preventive care, and the role of value-based care in managing their chronic conditions and overall health on-site and off-site.Guide patients in managing their health risks (e.g., hypertension, diabetes) and improving health outcomes through lifestyle changes, preventive screenings, and adherence to treatment plans.Help patients understand how addressing SDOH factors (e.g., housing, food, access to care) can improve their health and align with value-based care goals on-site and off-site.Community Outreach & Newly Assigned Outreach Initiatives
Participate in and coordinate community events to engage high-risk or underserved patients, ensuring they receive necessary preventive care and follow-up services.Follow up with community members who attended FCHC-sponsored or FCHC-participating events to connect them with FCHC-provided services and determine resources needed.Collaborate and maintain relationships with local community and social service organizations to address both clinical and non-clinical (educational) needs, helping to reduce health disparities and improve patient health journey overall.Data Management & Quality Improvement
Track patient outcomes and progress toward closing care gaps, providing regular updates to the Quality Team on the status of health risk assessments and care coordination efforts.Contribute to quality improvement initiatives focused on value-based care, helping to streamline processes that improve care delivery and reduce healthcare costs.Qualifications
Education / Licensure / Certification
High school diploma or equivalent required.Medical or Clinical Certification required.Preferred Certified Community Health Worker (CHW) or the ability to obtain certification within a specified time frame (if applicable).Basic Life Support (BLS) certification required.Experience / Competencies
Minimum of three years of experience in a healthcare setting , with exposure to value-based care models , care coordination, and patient education.Experience conducting health risk assessments and working with high-risk or underserved populations to manage chronic conditions and improve health outcomes.Knowledge of social determinants of health (SDOH) and the role they play in patient outcomes and healthcare delivery.Experience with value-based care principles and quality improvement initiatives aimed at improving clinical outcomes and reducing unnecessary healthcare utilization.Strong customer service and communication skills to educate patients about the importance of value-based care, preventive services, and managing health risks.Proficiency in using Electronic Health Records (EHR) to document health assessments, track care coordination efforts, and monitor patient progress.Ability to collaborate with teammates and relate well to people from cultural / diverse backgrounds, as well as, have a passion for working with at-risk, culturally / diverse populations.Willingness to work Saturdays & flexible hours to meet the organization’s needs / demands.Reliable, dependable, and able to function independently.Working Conditions and Physical Demands
While performing the required duties, the employee is frequently required to stand, sit, walk, read, and be capable of lifting a minimum of ten pounds. Work is typically performed in a clinical or office environment, though some outreach efforts may require off-site travel. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.
