Community Services Coordinator| Braintree, Massachusetts

Join Our Team at Optum

Optum is a global organization that delivers care, aided by technology, to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, and data they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits, and career development opportunities.

Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

Schedule:

FT, 40 hrs. Monday - Friday, 8:30am - 5pm.

Location:

111 Grossman Dr. Braintree, MA . This role is Hybrid in MA. Will be required to work onsite for a minimum of 2 days per week and provide coverage at sister site when needed.

Primary Responsibilities:

• Contacts patients and families identified via registry or referred by care teams and program staff, to provide guidance, advocacy, and support throughout the care process, including transitions and specialty care needs.
• Forms and maintains relationships with patients and families, demonstrating sensitivity to health literacy, preferred language, cultural beliefs, identity, and values impacting care, and staying in touch over time when necessary to ensure gaps are addressed and care plan adherence is in place. Identifies potential gaps in care planning, condition self-management, and potential presence of barriers to adherence to their plan of care.
• Collaborates with primary care teams, case management, nurse case managers, specialists, behavioral health providers, nutrition, social work, insurers, and community partners to coordinate comprehensive care.
• Screens for at-risk and medically complex patients for clinical and social triggers (SDoH) that may require intervention and escalates concerns appropriately.
• Tracks and supports patient adherence to appointments, laboratory tests, diagnostic studies, referrals, and prescription compliance with goal of closing gaps in preventative health and chronic condition(s).
• Conducts high-volume patient outreach via telephone, patient portal messages, mailings, and virtual or in-person encounters to support care plans and follow-up needs.
• Processes and coordinates referrals, including specialty care, behavioral health services, and community-based resources.
• Assists patients and families in navigating insurance and benefit programs (e.g., Mass Health, Social Security, Common Health), as well as community resources addressing transportation, nutrition (WIC/SNAP), housing, utilities, and durable medical equipment.
• Provides direct support to patients and families accessing and navigating complex medical, behavioral health, and social service systems.
• Documents all outreach, care coordination activities, outcomes, and relevant patient information accurately in the electronic medical record to ensure continuity of care.
• Maintains up-to-date community resource lists and reviews population health tools such as registries to identify and address care gaps. Coordinates and leads regular panel or roster reviews, including chronic disease management and complex care reviews, to support team-based care planning.
• Supports Patient Advisory Council meetings and other patient engagement activities, including gathering feedback and assisting with implementation of improvement initiatives.
• Maintains collaborative relationships with community organizations, advocacy groups, and stakeholders to enhance patient support and access to services.
• Attending meetings, training, and community outreach or educational activities to support program goals and continuous improvement.
• Performs other duties as assigned.
• Accesses only the minimum necessary protected health information (PHI) for the performance of job duties. Actively protects the confidentiality and privacy of all protected health information they access in all its forms (written, verbal, and electronic, etc.) taking reasonable precautions to prohibit unauthorized access. Complies with all departmental privacy policies, procedures, and protocols. Follows HIPAA privacy guidelines without…