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Onamia, MN, USA | Hourly | 26.16-50.13 per hour | Full Time

Summary

The Community Health Coordinator is responsible for coordinating care and connecting patients with community and public health resources that promote wellness, improve access, and address social determinants of health. This position supports outpatient clinic operations by integrating preventive health initiatives, population health management, and social support services into the clinical environment.

The role may be filled by a Registered Nurse (RN), Licensed Practical Nurse (LPN), Licensed Social Worker (LSW), Licensed Marriage and Family Therapist (LMFT), or a bachelor's-level public health professional with relevant experience (ex. LADC).

Essential Duties and Responsibilities

Care Coordination and Case Management

+ Conduct assessments to identify patients with complex health or social needs, including chronic disease, behavioral health, or socioeconomic barriers to care.

+ Collaborate with providers and clinic staff to implement individualized care plans and ensure continuity of care.**

+ Facilitate referrals and link patients to community programs, public health services, and behavioral health resources.**

+ Monitor patient progress and provide ongoing follow-up to support adherence to treatment plans and care coordination goals.**

+ Support transitions of care following hospital discharge or emergency visits to prevent readmissions.*

Community Resource Development and Collaboration

+ Maintain current knowledge of available community and public health programs, including transportation, housing, food access, and financial assistance.

+ Develop and sustain partnerships with local agencies, county public health departments, and community organizations.**

+ Represent the clinic and health system at community meetings, coalitions, and outreach events.***

+ Assist in developing internal processes and workflows that integrate community referrals into clinic operations.**

Education and Outreach

+ Provide patient education regarding preventive health measures, chronic disease management, and available support programs.**

+ Educate clinic staff on community resources and eligibility requirements for assistance programs.**

+ Participate in and assist with health promotion events, screenings, and outreach initiatives.**

+ Support population health programs that promote immunizations, wellness, and preventive care.

Quality Improvement and Reporting

+ Participate in quality improvement projects and initiatives related to population health, care coordination, and value-based care.

+ Collect and report data related to patient outcomes, resource utilization, and care gap closure.

+ Contribute to policy development, workflows, and reporting that align with regulatory and accreditation standards.

+ Utilize the electronic medical record system to document social determinants of health, interventions, and patient outcomes.*

Qualifications

Education and Licensure (one of the following required):

+ Registered Nurse (RN) with current Minnesota licensure; or

+ Licensed Practical Nurse (LPN) with current Minnesota licensure; or

+ Licensed Social Worker (LSW) or Licensed Marriage and Family Therapist (LMFT) licensed in the State of Minnesota; or

+ Bachelor's degree in public health, or a related human services field.

Experience:

+ Minimum of two (2) years of experience in a clinical, public health, or community-based setting preferred.

+ Experience with care coordination, resource navigation, or case management preferred.

+ Familiarity with outpatient workflows and multidisciplinary care models desired.

+ Comparable experience in a related field may be considered in lieu of direct experience requirements.

Knowledge, Skills, and Abilities:

+ Strong communication, critical thinking, and organizational skills.

+ Demonstrated ability to engage effectively with patients, families, and community partners.

+ Understanding of population health, social determinants of health, and trauma-informed care.

+ Ability to work independently and collaboratively within a multidisciplinary team.

+ Proficiency with electronic health records and documentation standards.

Working Conditions

Position primarily based in the outpatient clinic setting with potential for community outreach and home visits as appropriate. Will supply support to all clinic locations. Requires occasional travel to meetings, community events, and partner agencies.

Work schedules may vary depending on patient and community needs.

Supervisory Responsibility

Provides work direction in coordination with the Clinic Director.

Company Benefits Overview

+ Medical, Dental and Vision

+ Life Insurance and Voluntary Life Insurance

+ Paid Time Off

+ Tuition Reimbursement, Discounts and Scholarships Programs

+ Retirement Plans

+ Long-Term and Short-Term Disability

+ Health Savings Account

+ Flexible Spending Account

+ Wellness Program

+ Service and Pharmacy Discounts

+ Employee Assistance Program

+ Holiday Pay