Job Details: Job Location: 2020 J Street - Sacramento, CA, Position Type: Full Time, Salary Range: $21.00 - $23.00Hourly, Here at SNAHC, you are joining a team and company at a time of growth and transformation. You will love being surrounded by people who are as passionate as you are about healthcare and giving back to the community. Please note that individual total compensation for this position will be determined at the Company's sole discretion and the wage range for this role considers a wide range of factors including but not limited to skill sets; experience and training; licensure and certifications; and other business and organizational needs. At SNAHC, it is not typical for an individual to be hired at or near the top of the range for their role and compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current range is $21.00/HR-$23.00/HR.   Position Summary: The Care Coordinator supports patient engagement, care coordination, population health initiatives, and community-based resource navigation for assigned patient populations. This role works closely with providers, care teams, health plans, and community organizations to improve health outcomes, close care gaps, reduce barriers to care, and support patients in navigating the healthcare system.   The Care Coordinator provides proactive outreach and follow-up for preventive care, chronic disease management, transitions of care, and social determinants of health needs while supporting organizational quality and value-based care goals. This position serves as a trusted connection between patients and the healthcare team, helping patients access appropriate medical, behavioral health, and community support services.   This role is designed to support California Medi-Cal Community Health Worker (CHW) service requirements and population health initiatives in alignment with organizational and regulatory standards.   *Role may need to float to other SNAHC locations   Essential Functions: Care Coordination & Case Management Patient outreach Care planning Care transitions High-risk patient support Referral coordination   Population Health & Quality Care gap closure Registry management Panel management HEDIS/UDS/MCAS support Preventive services   Community & Resource Navigation SDOH assessment Community resources Transportation Housing Food access Benefits navigation   This role: Supports panel management and population health workflows for assigned providers and patient populations. Assists patients in navigating healthcare services, specialty referrals, behavioral health resources, transportation services, food resources, housing support, and other community-based programs. Identifies and address barriers impacting patient access to care and adherence to treatment plans. Reinforces provider-directed care plans, patient education, and self-management goals. Coordinates follow-up care for patients with chronic conditions, recent hospitalizations, emergency department visits, or identified high-risk needs. Collaborates with providers, nurses, behavioral health staff, health plans, and interdisciplinary teams to support coordinated patient care. Participates in daily huddles, care coordination meetings, and quality improvement activities. Maintains timely and accurate documentation in the electronic health record (EHR) and other population health platforms. Supports organizational performance goals related to health plan specific measures, HEDIS, UDS, CalAIM, value-based care, and other quality initiatives. Conducts outreach through telephone, telehealth, in-person visits, and community-based engagement activities as appropriate. Maintains knowledge of community resources and establish collaborative relationships with community organizations and partner agencies. Protect patient confidentiality and comply with HIPAA and all applicable organizational policies and procedures. Ensure compliance with HIPAA, OSHA, SCAR, and all applicable laws and internal policies. Perform other duties as assigned to support patient care and population health operations. Participate in internal quality improvement teams. Works with team members proactively to drive quality improvement initiatives in accordance with the mission and strategic goals for the organization, federal and state laws and regulations, and accreditation standards. Compliance with all state and federal laws and regulations, as they pertain to position including; HIPAA, sexual harassment, scope of practice, OSHA, etc   Competencies: Patient-centered communication Cultural humility and community engagement Care coordination and follow-through Problem-solving and resource navigation Team collaboration Organization and time management Adaptability and initiative Documentation accuracy and attention to detail Qualifications: Minimum Qualifications: Experience in ambulatory primary care practice Excellent communication and customer service skills with both staff and patients Familiarity with HEDIS, PQRS, and quality metric specifications Experience with Electronic Medical Record systems Knowledge of CPT, ICD, and HCPCS coding Thorough understanding of HIPAA compliance and patient confidentiality standards Preferred Qualifications: Certified Community Health Worker Experience working with underserved or vulnerable populations preferred. Knowledge of Medi-Cal, managed care, population health, or community resources preferred. Bilingual skills highly desirable. Experience in an FQHC, community clinic, health plan, or care management environment preferred.   Certification Requirement Employees hired into this role will be expected to obtain Community Health Worker (CHW) certification within a timeframe established by the organization. The organization will support and cover the cost of the certification process in accordance with organizational guidelines.   Please Note: This position may be grant funded.  Continued employment is contingent upon renewed or additional funding and may be discontinued at the close of the grant cycle.  Grant funding for any position does not impart any contractual right, either expressed or implied, to remain in Sacramento Native American Health Center, Inc.’s employment for a specific period of time.  Grant funding does not affect the Sacramento Native American Health Center, Inc.’s status as an “at will” employer.