Community Services Coordinator

** Requisition number:
** 2368876

** Job category:
** Medical & Clinical Operations

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, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities.

Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start  
** Caring. Connecting. Growing together.*
* Under general supervision, the Community Services Coordinator is a vital member of the primary care team who facilitates the care process for at-risk and medically complex patients by addressing gaps in social determinants of health, coordinating accessible plans of care, screening for clinical and social triggers, and tracking adherence. Serving as a liaison among patients and families, primary care teams, specialist physicians, community resources, and interdisciplinary partners, the Community Services Coordinator forms relationships with patients and regularly identifies factors that impact care and treatment plans.

The Community Services Coordinator partners closely with clinicians, case management, and social work teams to process referrals and connect patients and families to specialty care, community resources, and social service agencies, addressing social determinants of health such as transportation, disability support, insurance reconciliation, housing, nutrition, and other essential services. The role provides direct patient and family support in accessing and navigating complex medical, behavioral health, and social service systems through in-person, virtual, and telephonic interactions.

Additionally, the Community Services Coordinator performs data management and patient outreach for an assigned population, populates standardized clinical and non-clinical information in the electronic medical record to ensure accurate care coordination, and generates reports to support population health and quality initiatives. The Community Services Coordinator ensures clinicians are informed of patient status, may present performance metrics, attend required specialty meetings, and participate in care improvement activities to support optimal health outcomes.

The Community Services Coordinator does not provide clinical services or medical advice.

** GENERAL DUTIES AND 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…