CLINICAL SERVICES COORDINATOR

THE PERKS: • Fun, challenging, and collaborative work environment with passionate colleagues that care deeply about healthcare delivery. • Recognized as One of the Best Places to Work in Healthcare by Modern Healthcare. • Competitive benefits programs including Medical, Vision, Dental, HSA, FSA, and 401k. • Fitness reimbursement, commuter benefits, and tuition assistance. • Great work life benefits- Paid time off, sick time, and 12 paid holidays. • Fully Remote Schedule WHAT YOU CAN LOOK FORWARD TO: Patient Outreach, Scheduling & Care Coordination • Conduct proactive patient outreach to support Annual Wellness Visits, Timely Follow-Up/Transitions of Care, preventive screenings, care management, chronic disease management, and other clinical initiatives. • Schedule, coordinate, and confirm patient appointments while addressing barriers to care and improving appointment adherence. • Coordinate services across primary care, specialty care, behavioral health, and community-based organizations. • Build collaborative relationships with patients, caregivers, providers, and community partners to improve care access and patient outcomes. • Provide patient education, reinforce care plans, and support self-management activities. • Assist patients in navigating healthcare services, insurance resources, transportation, and other community supports. Population Health & Preventive Care • Utilize EMR, population health registries, Agentic AI tools, and reporting platforms to identify patients due for preventive services, follow-up appointments, and quality interventions. • Support Annual Wellness Visit workflows, preventive care initiatives, quality measure performance, and value-based care programs. • Assist with standardized screenings and assessments, including health risk assessment, PHQ-9s and social determinants of health (SDOH) screening, as appropriate. • Monitor assigned patient work queues and outreach lists to ensure timely completion of clinical and operational priorities. • Collaborate with Care Transformation Partners to support health centers’ needs and participate in finding solutions to current challenges or barriers. Timely Follow-Up & Transitions of Care • Conduct timely outreach following emergency department visits, hospital admissions, and other care transitions to support continuity of care. • Coordinate post-discharge appointments, medication reconciliation or review, referrals, and additional follow-up activities as directed. • Identify and escalate clinical, behavioral health, or social concerns to licensed clinicians or appropriate members of the care team. Clinical Operations & Quality Improvement • Collaborate with providers and interdisciplinary teams to improve patient engagement, reduce care gaps, and achieve quality and population health goals. • Participate in quality improvement initiatives, workflow optimization, and implementation of new clinical programs. • Support standardized workflows and best practices across clinical service lines. • Assist with onboarding, training, and sharing best practices with team members as needed. • Contribute to optimizing and documenting workflows to establish standards of care, best practices, and policies. Documentation, Compliance & Technology • Maintain accurate, timely, and complete documentation within the EMR and care management platforms. • Ensure compliance with organizational policies, regulatory requirements, privacy standards, and documentation guidelines. • Utilize technology-enabled outreach platforms, AI-assisted patient engagement tools, and other digital solutions to enhance workflow efficiency and patient engagement. • Monitor outreach activities and documentation to support performance reporting and quality metrics WHAT YOU’LL NEED TO SUCCEED: • 3 years of work experience in care coordination or care/case management, patient outreach, and connecting to community resources • Bilingual in Spanish and fluent in medical terminology • Experience in one or more of the following settings: • Safety-net or public health hospitals • Federally Qualified Health Centers (FQHCs) • Academic medical centers • Ambulatory care • Physician groups or professional practices • Community Mental Health Centers • Substance use treatment settings • Outpatient mental health services • Current state licensure as an RN, LPN, LSW, or LCSW a plus. Additional state licensure may be required in any state where the employee provides patient care, including virtual or in-person care. • Experience in engaging patients with chronic illnesses and needs related to behavioral health and multiple social factors affecting health outcomes. • Knowledge and experience working with Medicaid and Medicare populations and in value-based care desirable.