Community Care Coordinator - Moffat County

The Bilingual Community Care Coordinators will conduct outreach and perform assessments for Northwest Colorado residents, specifically those enrolled in Medicaid and Medicare throughout the Yampa Valley. This position will serve as a liaison between clients and healthcare providers, including specialty providers and human service agencies to reduce barriers to care and assure clients receive the care they need when they need it.  The Care Team works with clients to identify barriers to care, and develop a comprehensive goal-oriented care plan.  

Supervision Received: The Care Coordinators are based out of the Routt or Moffat offices, supervised by the Care Team Supervisors.  

Supervision Exercised: none 

General Requirements & Qualifications: 

• Bachelor’s Degree or equivalent experience 
• Health or Human Services experience preferred 

• Engage in cross-organization efforts, connecting project work to the broader Partnership. 
• Share unique skills and expertise with NCCHP team  
• Working with clients, clinical practices, community social service providers, complex medical patients and knowledge of health service delivery preferred  
• Possess a Colorado driver’s license and have access to a reliable vehicle and be willing to travel throughout the counties, including during inclement weather 
• Ability to communicate effectively with diverse audiences including clients, community members, professional partners, funders and government agencies 

• Proficiency with Microsoft Outlook, Word, Excel, and PowerPoint 
• High level of organizational skills with a focus on problem solving, detail oriented and follow through 
• Active listening, motivational interviewing techniques, and the ability to support clients during intense emotional periods 
• Can support non-clinical community care team 
• Commitment to inclusiveness, social justice, health equity and reduction of health disparity 

• Identifying and using data for data informed decision making, and to enhance collaborative work 
• High tolerance for ambiguity and ability to problem solve and appropriate course of action 
• Knowledge of Maternal Child Health including screenings tools, developmental milestones,  

immunizations, etc) 

• Performs all other duties as assigned 

Essential Duties 

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

• Provide a variety of indirect and direct care coordination to clients identified as in need of services. This includes: 

• Form trusting collaborative relationships with clients and partner organizations and care coordinator II. 
• Schedule and complete assessments, follow-up as needed, track results, referrals and recommendations in database. 
• Meet with clients in public spaces or place of residence when appropriate to the clients’ needs. 
• Track and monitor referrals of clients for reporting as requested. 

• Accurately document interactions in population health data system (ESSETTE) to include client visits, needed services, phone calls, written correspondence and communication in appropriate computer system within 2 business days. 
• Work closely with partner organizations such as Horizons, Lift Up, Department of Human Services and other members of the Navigation Network to complete care plans. 
• Ability to connect with diverse client population, empathize, show compassion, perform assessments and develop and self-management plan in partnership with client and possibly other community partner agencies. 
• Coordinate care with providers, community partners and other patient navigators to provide outreach, referrals and support for Medicaid clients. 
• Complete documentation and reporting as required by program and supervisor. 

• Complete intakes of high-risk patients, working in partnership with patient, family and other members of the healthcare team as needed to assess and prioritize patient’s physical needs, mental well-being, family support system, financial resources and available community and government resources. 

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

• Co-create patient specific goals, objectives and measures that meet the patient’s needs and that have been identified through assessment. 

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

• Provide technical assistance to CCT across the region around ESSETTE and work with Rocky to improve the data and reporting system. 
• Collaborates with other Care Coordinators to ensure all program deliverables are being met and advise supervisor or CCT Coach of any needs for meeting deliverables such as monthly reporting, referrals, interventions, assessments, etc. 

Collaborate with Care Coordination Supervisors and other Care Coordinators to ensure all program deliverables are achieved and program evaluations are conducted 

• Participate in regular staff meetings. 
• Performs assigned work safely, adhering to organization and program established safety rules and practices. 

Assess and document effectiveness of care plans and share with Care Coordination Supervisor 

• Serve as liaison for Rocky Mountain Health to support a strong connection between RCCO/RAE, CCT and NCCHP. Share information in a proactive way with team and supervisor. 
• Conduct program evaluation tools within program requirements (client evaluations, success stories and work with CIVHC). 

Working Conditions 

• Up to 10% time traveling and flexible work schedule with some work remotely   
• Work location for administrative activity is in an accessible office environment   
• Daily activity is 80% sitting or standing with extended periods of typing at a keyboard, 20% walking with occasional stooping, bending, reaching, twisting.  
• Office equipment would include phone, computer, printer, copier on a daily basis  
• Independent travel throughout the region, including during inclement weather