Community Care Coordinator - PRN - (Flagstaff/Coconino County)

Adobe Care And Wellness LLC•Flagstaff, AZ

About The Position

Adobe Population Health (APH) is a women-owned health solutions company founded in 2018 and committed to positively impacting the lives we touch. The company has a culture of inclusivity and human kindness, based in Phoenix, AZ, with satellite locations in multiple states. APH has been recognized as one of “America's Fastest-Growing Private Companies” by Inc. 5000 and has earned a "Best Places to Work" award from the Phoenix Business Journal consecutive times. APH offers customized programs for insurance groups, providers, hospitals, and families, which include case management, in-home/in-clinic wellness assessments, preventative care, transitional care, and social work services. As one of the country's few fully integrated healthcare providers, APH provides top-notch medical services with various service lines. The company is expanding and looking for individuals who want to make a difference and help those in need. POSITION PURPOSE The Community Care Coordinator is responsible for providing comprehensive care coordination and management services to clients within an assigned territory. This role combines field-based care coordination with supervisory responsibilities, focusing on enhancing client outcomes through behavioral, physical, and social interventions. As a CCC, you will oversee case management activities, ensure compliance with organizational policies, and foster positive relationships with clients, caregivers, providers, and team members.  Additionally, you collaborate with healthcare providers, social services, and community organizations to identify and address barriers to health and well-being. The ideal candidate will be passionate about community engagement and equity, and skilled in connecting individuals with appropriate resources that improve their health outcomes. This position requires travel to Flagstaff, around Coconino County, and surrounding areas to provide in-home support to our members.

Requirements

Four to six years of related experience and/or training, or an equivalent combination of education and experience.
Must have the willingness to drive with a clean driving record.
Reliable transportation.
Clean driving record.
Excellent communication skills, both verbal and written.
Requires problem-solving and decision-making.
Must be able to work in a self-directed environment.
Identify and resolve problems in efficient and effective ways.
Takes personal responsibility for the quality and timeliness of work and achieves results with little oversight.
Adapts to changing business needs, conditions, and work responsibilities
Proficiency in Microsoft Office Suite.
Knowledge of confidentiality and data protection regulations, especially in relation to health information (e.g., HIPAA compliance).
Associate’s degree in Social Work, Sociology, Psychology, Counseling, or a related field required, OR active LPN/RN licensure, EMT, or Paramedic certification; Bachelor’s degree preferred.
Current BLS certification and annual TB testing required.
Current and clear driver’s license.

Nice To Haves

Medical experience strongly preferred.
Experience working with diverse populations, including marginalized, low-income, and underserved communities.
Bilingual (Spanish/English) preferred.

Responsibilities

Provide field-based care coordination to address behavioral, physical, and social needs of assigned clients, aiming to reduce medical costs and improve quality of life.
Assess the social, financial, and health needs of individuals and families within the community.
Connect clients with appropriate services, including housing assistance, food security programs, healthcare services, transportation, and mental health resources.
Develop and implement individualized care plans in collaboration with clients, ensuring that their unique needs are addressed.
Provide ongoing support to ensure clients' needs are met, including follow-ups and reassessments.
Advocate on behalf of clients to ensure they receive timely access to services and resources.
Offer education on physical health, illnesses, treatments, dietary concerns, stress management, and safe medicine use.
Provide emotional support to clients and manage their overall well-being.
Support clients in developing self-care strategies and accessing preventive health services.
Encourage clients to actively engage in their health and well-being through empowerment and education.
Conduct home safety evaluations and monitor client progress through regular home visits.
Connect clients with appropriate community services and resources.
Build and maintain strong relationships with local community organizations, healthcare providers, and government agencies to ensure access to a wide range of resources.
Participate in outreach efforts to identify individuals and families in need, particularly in underserved or marginalized communities.
Represent the organization at community events, health fairs, and workshops to promote services and educate the public about available resources.
Identify trends and emerging needs within the community to inform organizational planning and service delivery.
Maintain accurate records of care coordination in the Electronic Medical Record (EMR) system and ensure compliance with HIPAA regulations.
Document interactions, care plans, and outcomes in accordance with organizational policies and confidentiality guidelines.
Track and report on the effectiveness of referrals and interventions to help identify gaps in services or areas for improvement.
Maintain accurate records of client information and provide timely reports to supervisors and funding agencies as required.
Participate in program evaluation and quality improvement initiatives.
Ensure adherence to Adobe policies and procedures, and assist in developing and updating company programs, policies, and procedures as needed.
Develop and maintain positive relationships with case managers, providers, administration, and other stakeholders.
Travel to assigned territories for training, meetings, and as requested by upper management. Attend all applicable facility and management meetings.
Completes other duties and responsibilities as assigned.
Maintain availability for a minimum of one (1) eight-hour shift per week.
Work a minimum of four (4) shifts per month to remain active in the PRN Staffing Program.
Respond and assist with staffing requests at least three (3) out of every four (4) times contacted when reasonably available.
Report to assigned shifts at scheduled start times or within two (2) hours when covering unplanned absences.
Accept assignments within designated service areas as directed by leadership.
Notify management in advance of any known periods of unavailability following company policy.