Job Description

This role assists primary care providers, nurses, and care managers with complex situations related to resolving the SDOH needs of our members. The SDOH Coordinator supports our members by linking them to the community resources that meet their SDOH needs through referrals, assistance with completing applications and follow up. Skills that are key to the success of this position include maintaining knowledge of community resources, understanding eligibility requirements and application processes for benefits and resources (e.g., health plan benefits, entitlements, SNAP, housing/shelter programs, transportation), identifying the appropriate resource for each member’s unique situation, and organizational skills to follow up timely to ensure successful access to resources.

Duties and Responsibilities

• Receive referrals from the Integrated Care Team (ICT) to address members’ SDOH needs as identified during routine assessment or as requested by the member.
• Assist members with referrals and coordinating services with community resources including, but not limited to:
• Housing, e.g., voucher programs, halfway houses, shelters
• Government benefits, e.g., SNAP, phones, transportation
• Food and personal/household items e.g., food pantries, soup kitchens, homeless outreach centers, clothing, seasonal resources such as toy and backpack drives, winter clothing closets
• Utility assistance, e.g., LIHEAP
• Advocacy including coordinating letters of medical necessity related to eviction or utility shut off notices
• Obtaining picture ID and/or birth certificate documents
• Medication assistance, i.e., enrolling patients in any assistance available for medication co-pays
• Transportation, e.g., health plan eligibility, public transportation / bus passes
• Educational and vocational resources
• Update the local Center’s Community Resource Guide when needed.
• Collaborate with ICT related to services not covered by the health plan.
• Exhaust all community and health plan options prior to requesting additional funds for SDOH items.
• Work closely with the local Resource Specialist related to member fund requests for SDOH expenses not otherwise provided in the community or covered by the health plan.
• Work closely with the local Resource Specialist related to ordering, distributing, tracking, and reporting on the local Center’s SDOH inventory of on-demand items.
• Work closely with the Behavioral Health team related to mental health and substance use services and referrals.
• Participate in integrated care team huddles, population health meetings, and ad-hoc case consultations.
• Follow primary care provider action plan to meet member needs.
• Coordinate with local licensed behavioral health professional (e.g., Supervisor, Manager, Behavioral Health Care Manager) for support and clinical oversight to complete referrals requiring clinical assessment or intervention.
• Coordinate with Community Health Workers (CHW) to meet the SDOH needs of members in the community.
• Communicate with assigned care managers and interdisciplinary care team to provide status of barriers, interventions, and referrals to facilitate continuity of care.
• Work with members directly while in the center to engage, build relationships, and connect to SDOH resources.
• Meet with members in the community, as necessary.
• Engage members telephonically.
• Document all interactions with the member and/or on behalf of the member in the electronic health record following required timeliness standards of documentation.
• Prioritize tasks to ensure requests are completed in a timely manner by appropriately discerning the urgency of the need and meeting response time performance metrics.

Minimum Qualifications

• Bachelor’s degree in public health, social work, human services or related health care field or equivalent experience of 3 years’ experience in serving the needs of complex populations.
• 2 years’ experience in serving the needs of complex populations (e.g., Medicaid, Medicare, uninsured), preferably in a healthcare or social services setting.
• Extensive knowledge of local community resources and entitlement/application processes
• Strong teamwork skills to work effectively within an integrated care team.
• Strong written and oral communication skills.
• Strong interpersonal skills to build relationships with staff, members, and community stakeholders.
• Ability to work independently to complete and follow up on assigned tasks.
• Problem solving skills.
• Operates personal motor vehicle.
• Hold and maintain active driver’s license and proof of insurance in state of practice.
• Passion for addressing health disparities and social needs of low-income, high-risk populations of diverse backgrounds, ages, and abilities.
• Proficiency in computer software including Outlook, Word, Excel, PowerPoint.
• Comfortable communicating by video conference and phone.
• Experience with electronic health record documentation preferred.

Working conditions

This job operates in a professional office environment and out in the local community. This role routinely uses general office equipment. This role requires access and use of own reliable transportation, current driver’s license, and proof of insurance to complete visits out in the community as needed.

Physical requirements

• Ability to communicate clearly and exchange accurate information constantly.
• Ability to remain stationary for long periods of time.
• Constantly operates computer, keyboard, copy and fax machine, phone, and other general office equipment.
• Operates personal motor vehicle.

• Ability to occasionally move objects up to 20 lbs.