Integrated Community Care Coordinator - Moffat County

Integrated Community Care Coordinator

The Integrated Community Care Coordinator plays a vital role in helping community members across the Yampa Valley access the healthcare, support services, and resources they need to thrive. This position works directly with Medicaid & Medicare clients to reduce barriers to care, build meaningful relationships, and coordinate support across healthcare providers, specialty care teams, and community organizations. Partner with clients to identify goals, navigate complex systems, and develop personalized, goal-oriented care plans that support overall health and well-being.

This role is ideal for someone who is compassionate, adaptable, highly organized, and passionate about improving health equity in rural communities.

The successful candidate will exhibit the following:

• Culture Champion – Commitment to The Health Partnership's mission and a passion for improving community health and well-being
• Results Producer – A results-focused mindset with a proven track record of exceeding goals
• Agility – Ability to think strategically, foresee opportunities and challenges, and adapt as needed
• Strong Communicator – Excellent written and verbal communication skills with the ability to build trust and connect with diverse individuals and partner organizations
• Organization – Exceptional capacity to manage multiple responsibilities, maintain accurate documentation, and follow through on program deliverables
• Action Oriented – Comfortable navigating changing priorities, solving problems creatively, and taking initiative in a fast-paced environment

Supervision Received:
The Care Coordinators are based out of the Routt or Moffat offices, supervised by the Care Coordination Program Manager

Key Accountabilities

Conduct outreach and provide assessment of Routt, Moffat, and Rio Blanco County residents who are enrolled in Medicaid/Medicare

• Call or text current Medicaid/Medicare members to offer care coordination support
• Track and monitor referrals of clients for reporting as requested
• Complete health and well-being assessments on each client
• Accurately document interactions in electronic health record (EHR) including client visits, needed services, phone calls, written correspondence and communication in appropriate computer system, in a timely manner

Educate and work with clients to develop a comprehensive, goal-oriented care plan, including identifying barriers to care

• Build trusting, collaborative relationships with clients, caregivers, healthcare providers, and community partners
• Meet clients in community settings or client residences when appropriate to support client needs
• Monitor client progress and assess the effectiveness of care plans, adjusting support strategies as needed
• Support clients through complex or emotionally challenging situations using active listening, empathy, and motivational interviewing techniques

Ensure that clients are connected to resources and community partners identified in their care plan

• Collaborate closely with healthcare providers, human service agencies, and community organizations to coordinate referrals and connect clients with healthcare, behavioral health, and other community-based resources.
• Collaborate with patients, families, healthcare teams, and community partners to assess and prioritize client needs, including physical health, mental well-being, financial stability, and social support systems

Collaborate with the manager and care coordination team to achieve program deliverables, conduct program evaluations, and assess and document care plan effectiveness.

• Maintain accurate and timely documentation of client interactions, referrals, assessments, care plans, program evaluations, and reporting requirements within established systems and timelines.
• Track referrals, interventions, assessments, and program outcomes while supporting regional care coordination efforts through data tracking, reporting, and continuous process improvement initiatives
• Perform all work in accordance with organizational safety practices and program standards

General Requirements & Experience

• Bachelor's degree in a related field or equivalent professional experience required
• Experience in…