Community Services Coordinator

Requisition Number: 2368876
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 insurance and benefit programs (e.g., MassHealth, Social Security, CommonHealth), as well as community resources addressing transportation, nutrition (WIC/SNAP), housing, utilities, and durable medical equipment.
• Provides direct support to patients and families accessing and navigating complex medical, behavioral health, and social service systems.
• Documents all outreach, care coordination activities, outcomes, and relevant patient information accurately in the electronic medical record to ensure continuity of care.
• Maintains up-to-date community resource lists and reviews population health tools such as registries to identify and address care gaps.
• Coordinates and leads regular panel or roster reviews, including chronic disease management and complex care reviews, to support team-based care planning.
• Supports Patient Advisory Council meetings and other patient engagement activities, including gathering feedback and assisting with implementation of improvement initiatives.
• Maintains collaborative relationships with community organizations, advocacy groups, and stakeholders to enhance patient support and access to services.
• Attends required meetings, trainings, and community outreach or educational activities to support program goals and continuous improvement.
• Performs other duties as assigned.

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required:

• 1-3+ years of experience in a clinical setting
• High School diploma or equivalency certificate (e.g. GED, HiSET, TASC Test) from an accredited institution or governmental unit required
• Active Driver's license and reliable transportation

Preferred:

• Previous training or experience work in healthcare and/or human services preferred
• Computer skills includes Electronic medical record (EMR) experience preferred
• A bachelor's degree in related field (typically in healthcare administration, psychology, sociology, Human Services, etc) preferred
• Bi-lingual candidates are encouraged to apply

SKILLS

• Knowledge and understanding of medical/healthcare terminology is strongly preferred
• Strong interpersonal and communication skills are needed with the ability to interact effectively with patients and medical professionals
• Ability to demonstrate a high level of cultural competence and sensitivity to patient needs and concerns. Ability to engage patients in problem solving
• Sound judgment with the ability to work and make decisions in a fast-paced environment
• Proficiency with Microsoft Office - especially Word and Excel are required
• Excellent telephone skills, strong customer service and ability to build relationships with patients are required

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will rangefrom $18 to $32 annually based on full-time employment. We comply with all minimum wage laws as applicable.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location, and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
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