The SDOH Care Coordinator identifies and addresses social determinants of health by connecting patients to community resources and primary care. They collaborate with interdisciplinary teams to manage referrals and document patient progress within EMR platforms.
Requirements summary
Requires an Associate degree in Human Services or a related field and at least 2 years of experience in SDOH support and motivational interviewing. A Bachelor's degree in Social Work or Public Health is preferred.
Join Community Community Health Network was created by our neighbors, for our neighbors.
Over 60 years later, “community” is still the heart of our organization.
It means providing our neighbors with the best care possible, backed by state-of-the-art technology.
It means getting involved in the communities we serve through volunteer opportunities and benefits initiatives.
It means ensuring our dedicated caregivers can learn and grow to stay at the top of their fields and to better serve our patients.
And above all, it means exceptional care, simply delivered — and we couldn’t do it without you.
Make a Difference The SDOH Care Coordinator plays a key role in supporting patients by addressing Social Determinants of Health through direct outreach, resource connection, and care coordination.
This position engages patients across multiple settings, including by phone, in physician offices, in the home, and in hospital environments, to meet individuals where they are and help remove nonclinical barriers to care.
Working within a primarily remote or hybrid model, depending on role requirements, the Care Coordinator collaborates closely with an integrated, interdisciplinary care team to identify social needs, connect patients to appropriate community resources, and support overall care plan success.
Through relationship centered engagement and effective coordination, this role contributes to improved access, continuity, and patient outcomes.
Exceptional Skills and Qualifications Applicants for this position should be able to collaborate with others in a team setting, have excellent communication skills, and a positive attitude toward problem-solving.
2 year / Associate Degree in Human Services, Public and Community Health, Health Services, or Behavioral Health (Required) 4 year / Bachelor's Degree in Social Work, Public and Community Health, Behavioral Health, or Health Services (Preferred) 2+ years: Experience with Providing SDOH support and community resource connection. (Required) PROVIDE RESOURCE CONNECTION AND NAVIGATION: Identify, connect, and support patients in accessing primary care, behavioral health, respite care, and other community based services based on individual needs.
Maintain and regularly update a comprehensive inventory of local and regional community resources to ensure timely and equitable access for patients and care partners.
Apply a solid working knowledge of Medicare, Medicaid, and third party payer guidelines to determine coverage eligibility and align patients with appropriate community and governmental resources.
CONDUCT SDOH SCREENING AND REFERRAL MANAGEMENT: Administer Social Determinants of Health (SDOH) screenings to assess and identify specific social needs impacting patient health and well being.
Based on screening results, make appropriate referrals to internal and external resources and conduct follow up with patients and providers to monitor progress, address barriers, and support successful connection to services.
COORDINATE CARE ACROSS THE INTERDISCIPLINARY TEAM: Coordinate care by sharing information, resources, and recommendations with referral sources, community agencies, and internal care partners to improve access to services, including primary care.
Collaborate closely with the Care Management team to support clinical education needs and care interventions when appropriate.
Engage with interdisciplinary team members to ensure alignment on individualized support plans, participate in care conferences for assigned caseloads, and provide insights or assistance to other team members as needed.
Ensure accurate, timely, and consistent documentation of required data within the EMR and Care Management platforms.
ENGAGE AND SUPPORT PATIENTS THROUGHOUT THE CARE JOURNEY: Build trust and rapport with patients to promote engagement, self-efficacy, and active participation in their care.
Interact with patients through multiple settings—including phone, physician offices, patient homes, and hospital environments—to meet patients where they are and support care coordination needs.
Provide clear education regarding available resources, care plans, and expected next steps, and utilize a variety of outreach strategies tailored to diverse populations to encourage ongoing participation and follow up
