The Care Coordinator will provide interdisciplinary care coordination services for the medical clinic. Care Coordination services will include the daily tasks of increasing patients' access to care, advocacy of patient needs, community connection to resources, obtaining medical support needs, assisting with crisis resources, and case management services. Applicants that are empathic, critical thinkers, work well individually and within a care team, are reliable, organized, and proficient with electronic health record systems will align well with this position.
DUTIES AND RESPONSIBILITIES:
General Care Coordination Duties - 50% FTE
- Serves as the primary point of contact for patients needing assistance navigating healthcare services.
- Coordinates appointments, follow-up visits, referrals, labs, imaging, and specialty care.
- Ensure timely patient outreach for completion of preventive services (annual wellness visits, immunizations, cancer screenings).
- Monitor the electronic medical record (EMR) and other registries to identify patients with care gaps (e.g., diabetes mellitus, hypertension not controlled, overdue colorectal cancer screening).
- Provide outreach to patients who are overdue for care or lost to follow-up.
- Conduct post-discharge calls to support transitions of care after ER visits or hospitalizations.
- Connect patients to community resources, social services, or internal programs (CHWs, physical therapy, dental services, behavioral health).
- Provides trauma informed resource support and assistance to providers for patients in need of emergency shelter due to homelessness and resources for food insecurity.
- Assist with applications or referrals for assistance programs as appropriate.
- Document outreach efforts and patient outcomes in the EHR.
- Participate in quality-improvement initiatives by providing data, insights, and workflow suggestions
- Track patients for follow-up to meet UDS, HEDIS, or value-based care quality measures.
- Responsible for accurate and timely contributions to all project reporting requirements.
- Attends and participates in other meetings and conferences as appropriate and/or identified by supervisors.
- Identify barriers to patient compliance and assist patients in overcoming such barriers.
- Monitor referrals in EMR for SDOH needs and assist accordingly.
- Propose and follow PDSA's relevant to the above.
- When necessary and appropriate, coordinate care with the family of the patient and clinical staff.
Diabetes Mellitus (DM) Clinic - 50% of FTE
- Provides concentrated effort working with the DM Care Team to include: DM Clinic providers, nursing staff, medical assistants, dieticians, and quality improvement team.
- Serves as first-line point of contact for diabetic patients needing additional support.
- Works with health information technology staff to analyze population-health reports and identify high-risk patients for outreach.
- Conducts outreach to patients with a diagnosis of diabetes, uncontrolled A1c levels, overdue labs, or missed appointments.
- Collaborates with medical reception to facilitate timely scheduling of DM Clinic appointments.
- Serves as a source of information for primary care providers and their patients for DM Clinic services.
- Provides patient assistance with connecting to external resources, i.e. endocrinology, podiatry, ophthalmology, nutrition, and behavioral health.
- Tracks and monitors diabetic patients to improve A1c control, blood pressure control, and preventive screenings.
- Supports transitions of care following ED visits or hospitalizations related to diabetes.
- Provide education on blood glucose monitoring, medication adherence, insulin use (if within scope), and lifestyle changes.
- Reviews blood glucose logs with patients and escalates concerns to providers.
- Assist in the coordination of care plans with providers, RNs, dietitians, pharmacists, community health workers, and behavioral health teams.
- Assist in the coordination of care plans with providers, RNs, dietitians, pharmacists, community health workers, and behavioral health teams.
- Attend team huddles, case conferences, and care-management meetings.
- Communicate patient progress, barriers, and care-plan adjustments effectively.
- Teach patients about diabetes pathophysiology, medications, nutrition basics, exercise, and risk-reduction strategies.
- Provide culturally sensitive, health-literacy-appropriate education materials.
- Support goal-setting, shared decision-making, and motivational interviewing
- Maintain accurate and timely documentation in the electronic health record (EHR).
- Document education provided, outreach attempts, care plans, and patient follow-up.
- Works closely with quality improvement teams to achieve UDS/HEDIS benchmarks (e.g., A1c control, kidney health evaluation, statin therapy, retinal exam completion).
- Participate in ongoing QI initiatives, data review, and performance-improvement projects
- Monitor quality metrics and generate reports when needed.
- Ensure compliance with HIPAA, clinic policies, and care-coordination protocols.
- Connect patients to community resources such as diabetes education programs, food support, transportation assistance, and financial aid.
- Assist with medication access, including PAP programs, pharmacy coordination, and insurance barriers
EDUCATION & EXPERIENCE
- Bachelor's degree in field of nursing and/or Social Work.
- Care Coordinator/Care Manager experience.
- Experience working with patients with chronic diseases, preferably diabetes.
- Strong communication, organizational, and patient engagement skills.
- Proficiency with electronic health records and population-health tools.
Preferred
- RN with diabetes education experience, Medical Social Worker, and/or applicant with care coordination experience
- Certified Diabetes Care and Education Specialist (CDCES) or eligibility.
- Experience in FQHC, primary care, or value-based care environments.
- Experience using registries, panel-management tools, and quality-measure platforms.
SKILLS:
- Good interpersonal skills, ability to get along well with diverse personalities (patients, physicians, staff, and general public).
- Ability to manage aspects of a project and provide patient care coordination.
- Good communication skills, written and verbal.
- Able to work independently, solve problems, manage multiple demands, recognize tasks, implement, and follow through to completion.
- Sound judgment and capability to respond to unusual circumstances.
- Able to deal constructively with conflict.
- Ability to plan, coordinate, and direct varied and complex cases.
OTHER SIGNIFICANT FACTORS:
The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. While performing the duties of this job, the employee is regularly required to sit; use hands to manipulate objects, tools or controls; reach with hands and arms; and talk and hear. The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and the ability to adjust focus. Noise level in the work environment is usually quiet.
Work is performed in an office environment utilizing various office equipment including, but not limited to, a computer, copy machine, fax machine, and multi-line phone. Ability to communicate effectively over the telephone, by computer and in person. Ability to perform well in a fast-paced work environment.
This is a general outline of the essential functions of this position and shall not be construed as an all-inclusive description of all work requirements and responsibilities. The employee may be required to perform other job-related duties as requested by the designated work leader(s). All requirements are subject to change over time. All positions at the Gerald L. Ignace Indian Health Center have the responsibility to carry out functions to maintain inspection and survey readiness, participate in Quality Improvement initiatives, as well as assist in and/or provide education for health promotion and disease prevention. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position.
GLIIHC supports a safe, healthy, and drug-free work environment through criminal and caregiver background checks and pre-employment drug testing. GLIIHC maintains a smoke-free environment.
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Gerald L. Ignace Indian Health Center, Inc.
$26.50 - $29.00 - At Gerald L. Ignace Indian Health Center, we offer a competitive package designed to support your health, financial future, and work-life balance.
Dec 15, 2025