The posting
The Care Coordinator for the Indian Health Service (IHS) 4-in-1 Grant Program plays a critical role in improving health outcomes for the urban American Indian and Alaska Native (AI/AN) community by coordinating culturally responsive services across the four grant program areas: health promotion and disease prevention (HP/DP), immunization services, alcohol and substance abuse services, and mental health services. This position is responsible for providing comprehensive, patient-centered care coordination that addresses the clinical, behavioral, and social drivers of health, with respect for custom and tradition. The Care Coordinator collaborates closely with internal providers, external partners, and community-based organizations to ensure continuity of care, effective resource utilization, and achievement of 4-in-1 grant objectives and deliverables. Essential Duties and Responsibilities: Primary Functions:
Coordinate with clinical staff to conduct comprehensive health assessments, including medical, behavioral, functional, and social determinants of health (SDOH), for patients served under the 4-in-1 grant program areas. Coordinate with clinical staff to develop, implement, and update individualized care plans that reflect patient goals, needs, and measurable outcomes, ensuring alignment with 4-in-1 grant objectives and HRSA/UDS clinical performance measures (e.g., diabetes, hypertension, depression screening, immunizations).
Primary Functions: continue
Coordinate care across primary care, behavioral health, dental, substance use, housing, and specialty systems to address whole-person health needs in accordance with the integrated services model and the four 4-in-1 program areas (HP/DP, immunizations, alcohol/substance abuse, and mental health) Track and follow up on referrals to specialty care, housing services, substance use treatment, behavioral health, and other wraparound supports. Coordinate multidisciplinary team meetings and case conferences with providers, behavioral health clinicians, community health workers, and social services Document all care coordination interactions and interventions in the EHR and grant tracking systems within required timeframes. Collaborate with grant stakeholders as needed to ensure program compliance and alignment. Identify and resolve barriers to care, including access to transportation, medication adherence, or cultural/language needs. Participate in population health initiatives, quality improvement activities, and care team huddles to enhance patient outcomes and operational effectiveness Monitor high-risk patient panels using risk stratification tools and provide appropriate intensity of services based on patient acuity. Provide patient navigation support, health system education, and linkage to resources. Maintain current knowledge of 4-in-1 grant program requirements, IHS/Urban Indian health program benefits, Medi-Cal benefits, and community resources. Maintain complete, timely, and compliant documentation for all services provided, supporting 4-in-1 grant deliverables, quarterly progress reports, compliance monitoring, and required program reporting Respond to crises and escalating needs with urgency, de-escalation skills, and coordination with emergency or behavioral health resources. Participate in required grant data collection and reporting processes, including the annual Uniform Data System (UDS), Government Performance and Results Act (GPRA) measures, and the National Immunization Reporting System (NIRS), contributing relevant care coordination and clinical data. Maintain confidentiality and comply with all HIPAA regulations and grant program data-sharing requirements. Active involvement in the community to educate about risk factors for chronic disease, increase community-based screening methodologies, and recruit newly diagnosed individuals to SDAIHC for treatment and management. Assist with program evaluation, including the 4-in-1 national evaluation, performance measurement, patient satisfaction surveys, and continuous quality improvement related to IHS and HRSA funding expectations Adhere to organizational and departmental policies and procedures. Perform the clinical and administrative duties necessary to meet the goals and objectives of the grant. Maintain an assigned patient case load as established by program leadership Demonstrates accountability by completing assigned tasks accurately, on time, and in alignment with organizational policies and procedures Ensures work is completed with attention to detail, accuracy, and compliance with program. Other duties as assigned.
Minimum Qualifications:
Education and/or Experience: Bachelor’s degree in social work, public health, psychology, or related field or equivalent experience in care coordination/ case management. Ability to view the patient as a whole person within the context of their family and community. Excellent interpersonal and communication skills. Computer and analytic skills to run reports and review data. Minimum of 2 years of experience, preferably in community health, case management, or care coordination Must be a team player and be willing to put the needs of the patients first. Understand requirements for Patient Centered Medical Home. Experience working with vulnerable populations (e.g., individuals with SMI/SUD, homelessness, complex medical needs) Strong knowledge of Medi-Cal benefits, IHS/Urban Indian health programs, community resources, and health care delivery systems. Valid driver’s license and reliable transportation for community-based visits
Preferred:
FQHC background. Familiarity with community health clinics and/or Indian Health Clinics. ECW EHR. Prefer a master’s degree from an accredited university or professional school for a Nursing, and at least 2 years of experience; or a BA and 4 years’ experience
Disclaimer Nothing in this job description restricts management's right to assign or reassign duties and responsibilities to this job at any time. This description reflects management’s assignment of essential functions; it does not proscribe or restrict the tasks that may be assigned. This job description is subject to change at any time. Acknowledgement San Diego American Indian Health Center is an Equal Opportunity Employer. We encourage applications from all individuals regardless of race, religion, color, sex, pregnancy, national origin, sexual orientation, gender identity, gender expression, ancestry, age, marital status, physical or mental disability or any other protected class, political affiliation, or belief.
