Job Description

About SoHum Health

At SoHum Health, our mission is to provide high-quality local medical services and engage community members in education and lifestyle opportunities to promote optimal health and wellness. As the sole provider of emergency, acute, radiology, skilled nursing, pharmacy, and various other health services in our expansive rural region, we play a unique role as a hub and trusted partner for the patients we serve. Guided by our core values of caring, quality, teamwork, and positivity, we strive daily to improve the health of our underserved community.

Objective

The Population Health Care Coordinator is responsible for supporting individuals with complex medical, behavioral, and social needs through the Enhanced Care Management (ECM) and Community Health Worker (CHW) programs, providing compassionate, hands-on, whole-person care. The Population Health Care Coordinator establishes and maintains working relationships between patients, provider teams at SoHum Health, Partnership HealthPlan of California, and community-based organizations to ensure coordinated and responsive care delivery. This model utilizes a team-based approach focused on continuous partnership among the patient, caregiver, physician, hospital, and community resources to provide consistent, coordinated support and improve overall health outcomes.

The Population Health Care Coordinator conducts frequent in-person visits, coordinates medical and community-based services, advocates on behalf of members, and assists individuals in navigating healthcare and social service systems. Responsibilities include addressing barriers related to housing, food access, mental health, transportation, and other social determinants of health while serving as a trusted and reliable point of support for members. It is essential that the Population Health Care Coordinator maintains a current understanding of ECM programs, community resources, and care coordination practices to effectively support the diverse needs of the communities served.

Essential Functions

• Collaborate and coordinate services with patients/enrollees, family/caregivers, multi-disciplinary team members, providers, and community services to develop a comprehensive care plan and promote timely access to care
• Works with the patients/enrollees' care team to conduct comprehensive assessments and develop and update care plans for each patient/enrollee
• Conducts ongoing outreach and engagement with each member, primarily through in-person contact or the member's preferred method of communication
• Provides education and identifies support needs for a member and their family or caregivers
• Appropriately record social drivers of health and follow-up in the facility’s records
• Develop and maintain positive working relationships with community organizations and/or resources to identify potential resources for resolving patients’ health and social needs
• Use critical thinking skills to analyze issues, develop plans for improvement, implement plans in collaboration with others, and monitor intervention effectiveness
• Acknowledge patient’s rights and follow appropriate state and federal privacy and security regulations, including HIPAA, HITECH, and CMIA
• Work as a team player, willing and able to foster creativity, innovation, and collaboration
• Demonstrate organizational ability and time management
• Exhibit strong attention to detail to ensure accuracy and quality, and maintain an organized set of records for the functions performed within the scope of this position
• Effectively deal with change and competing priorities and work independently to produce high-quality, accurate, and timely results
• Attend conferences, courses, and educational forums as approved and complete annual education requirements, as applicable
• Attend meetings as appropriate

Core Competencies

Patient rights

Development of plans

Strong interpersonal skills

Teamwork and leadership

Requirements

Required Education and Experience

High School graduate or equivalent

Minimum of 1 year of experience in social services, case management, public health, or related field

CHW or willing to obtain within the first 18 months of employment

Preferred Education and Experience

Bachelor’s degree in social work, population health, or other related field

CHW

2-5 years of experience in social services, case management, public health, or related field