Integrated Community Care Coordinator - Routt County

The Integrated Community Care Coordinator plays a vital role in helping community members across the Yampa Valley access the healthcare, support services, and resources they need to thrive. This position works directly with Medicaid and Medicare clients to reduce barriers to care, build meaningful relationships, and coordinate support across healthcare providers, specialty care teams, and community organizations. Fluency in English and Spanish is preferred. The Care Coordination team partners with clients to identify goals, navigate complex systems, and develop personalized, goal-oriented care plans that support overall health and well-being. This role is ideal for someone who is compassionate, adaptable, highly organized, and passionate about improving health equity in rural communities. The successful candidate will exhibit the following: Culture Champion– Commitment to The Health Partnership’s mission and a passion for improving community health and well-being. Results Producer– A results-focused mindset with a proven track record of exceeding goals. Agility – Ability to think strategically, foresee opportunities and challenges, and adapt as needed. Strong Communicator– Excellent written and verbal communication skills with the ability to build trust and connect with diverse individuals and partner organizations. Organization– Exceptional capacity to manage multiple responsibilities, maintain accurate documentation, and follow through on program deliverables. Action Oriented– Comfortable navigating changing priorities, solving problems creatively, and taking initiative in a fast-paced environment. Supervision Received: The Care Coordinators are based out of the Routt or Moffat offices, supervised by the Care Coordination Program Manager. Supervision Exercised: None. Key Accountabilities: Conduct outreach and provide assessment of Routt, Moffat, and Rio Blanco County residents who are enrolled in Medicaid and Medicare Call or text current Medicaid/Medicare members to offer care coordination support. Track and monitor referrals of clients for reporting as requested. Complete health and wellbeing assessments on each client Accurately document interactions in electronic health record (EHR) including client visits, needed services, phone calls, written correspondence and communication in appropriate computer system, in a timely manner. Educate and work with clients to develop a comprehensive, goal-oriented care plan, including identifying barriers to care Build trusting, collaborative relationships with clients, caregivers, healthcare providers, and community partners. Meet clients in community settings or client residences when appropriate to support client needs. Identify client barriers to care and develop personalized, goal-oriented care plans. Monitor client progress and assess the effectiveness of care plans, adjusting support strategies as needed. Support clients through complex or emotionally challenging situations using active listening, empathy, and motivational interviewing techniques. Ensure that clients are connected to resources and community partners identified in their care plan Coordinate referrals and connect clients with healthcare, behavioral health, social service, and community-based resources. Collaborate with patients, families, healthcare teams, and community partners to assess and prioritize client needs, including physical health, mental well-being, financial stability, and social support systems. Collaborate closely with healthcare providers, human service agencies, and community organizations throughout the region. Collaborate with Care Coordination Manager and other Care Coordinators to ensure all program deliverables are achieved, and program evaluations are conducted. Assess and document effectiveness of care plans and share with Care Coordination Manager Maintain accurate and timely documentation of client interactions, referrals, assessments, and care plans within required systems and timelines. Track referrals, interventions, assessments, and program outcomes to support reporting and program evaluation. Support regional care coordination efforts by assisting with data tracking, reporting, and process improvement initiatives. Complete program documentation, evaluations, and reporting requirements as assigned. Perform all work in accordance with organizational safety practices and program standards. General Requirements & Experience: High school diploma or equivalent required. Bachelor’s degree in a related field or equivalent professional experience preferred. Fluency in English and Spanish is preferred. Experience in healthcare, human services, community health, care coordination, or social services preferred. Engage in cross-departmental collaborative efforts, connecting project work to the broader organization. Experience working with diverse populations through direct client work and/or case management preferred. Ability to communicate effectively with clients, community members, healthcare providers, partner organizations, funders, and government agencies. Proficiency with Microsoft Outlook, Word, Excel, Teams, and PowerPoint. Strong organizational skills with attention to detail, problem solving, and follow-through. Ability to support clients through complex or emotionally challenging situations using active listening, empathy, and motivational interviewing techniques. Ability to work independently while also collaborating effectively within a team environment. Commitment to inclusiveness, social justice, health equity, and reducing barriers to care. Ability to use data to support informed decision-making and collaborative work. Comfortable navigating ambiguity and identifying practical solutions to challenges. Must possess a valid Colorado driver’s license, maintain reliable transportation, and be willing to travel throughout the region, including during inclement weather. Must provide proof of a valid driver’s license and adequate insurance coverage totaling at least $300,000 per occurrence. Performs all other duties as assigned. Working Conditions: This role includes a combination of office-based, community-based, and remote work. Regular travel throughout Routt, Moffat, and Rio Blanco counties is required. Flexible scheduling may be available based on program and client needs. Work location for administrative activity is in an accessible office environment. Daily activity is 80% sitting or standing with extended periods of typing at a keyboard, 20% walking with occasional stooping, bending, reaching, twisting. Office equipment would include a phone, computer, printer, and copier on a daily basis. Independent travel throughout the region, including during inclement weather. Compensation: This is a salaried, non-exempt position, compensated on a salary basis and eligible for overtime pay for all hours worked over 40 in a work week, in accordance with applicable state and federal laws. $56,650-$59,000 per year. Why Join The Health Partnership? Meaningful, community-centered work that directly impacts local residents Collaborative and mission-driven team environment Opportunity to improve access to care and health equity across Northwest Colorado Flexible, relationship-focused work environment Inclusive and supportive workplace culture Our Vision: The Health Partnership is a trusted leader and community partner in helping all in the Yampa Valley have equitable access to health and well-being resources. Our Mission: To compassionately connect people to health and well-being resources so they can thrive. Our Welcoming Work Culture:The Health Partnership is proud to be a neurodivergent, LGBTQ+, and culturally inclusive organization. We are committed to creating an environment where people of all backgrounds, identities, and abilities feel respected, supported, and empowered to thrive.