Social Determinants of Health (SDOH) Care Coordinator

Klamath Health Partnership, Inc., (KHP) is a Federally Qualified Health Center whose mission is to provide accessible, quality-driven, responsive, patient-centered health services to the community, with an emphasis on those who need us most. Staffed by a comprehensive team of over 50 health professionals and over 100 support personnel, KHP is the second largest healthcare provider in the Klamath Basin.

The SDOH Care Coordinator works in collaboration with patient care teams to capture information that may identify barriers to health experienced by the patients of Klamath Health Partnership (KHP). This position focuses on decreasing health inequities and increasing access to supportive services available within the organization and community. The Care Coordinator will also oversee the objectives and requirements of the Health-Related Social Needs (HRSN) grant by assisting patients with the authorization and approval process and ensuring all elements of the application are completed appropriately.

Essential Duties and Responsibilities:

• Determines eligibility and completes the application process for patients eligible to receive services from HRSN program.
• Ensures compliance for all elements of the grant and identifies any training, workflow or process gaps. Complete all required trainings.
• Attend meetings with OHA not less than once per month.
• Works with finance team to provide quarterly expenditure reports for funds dispersed.
• Assists with the development and updates needed for the organizational SDOH workflow.
• Partners with the Community Health Worker (CHW) team to coordinate resources available for SDOH needs.
• Works with the Data team to ensure accurate SDOH screening data is captured within the EHR, per quality measure specifications, and is reportable. Remains up-to-date on Oregon Health Authority (OHA), Patient-Centered Primary Care Home (PCPCH), and Uniform Data System (UDS) recommendations and requirements related to SDOH.
• Documents resources and assistance provided, makes appropriate referrals when indicated, and works to close the loop on referrals.
• Maintains a knowledge of SDOH and Health-Related barriers our patients may experience with a focus on providing accessible, culturally sensitive, quality-driven, patient-centered services, with an emphasis on under-served. Acts as the SDOH Subject Matter Expert (SME).

Other Duties:

• Assists with transportation services and the scheduling of transport for KHP patients.
• Attends community outreach events to provide information for services available at KHP and engage with community partners.
• Participates in various Quality Department meetings, works in collaboration with the Quality & Data team.
• Tracks the status and progress of the HRSN work within the organization.
• Develops and maintains SDOH resources to provide current information regarding assistance available for identified barriers.
• Maintains confidentiality and complies with HIPAA rules and regulations.

Desired Knowledge, Skills, and Abilities:

• Strategic and opportunistic thinker.
• Ability to articulate a vision for the SDOH work of KHP and develop and sustain multi-stakeholder collaboration in support of the mission and vision.
• Ability to utilize and integrate multiple resources to fill gaps in health inequities.
• Excellent organizational skills with the ability to manage multiple tasks and timelines.

Qualification/Requirements:

• Skilled in specialized computer skills including spreadsheet, reporting writing, project management, word processing, and various software usage.
• Experience working within the health-care field, social services, community health work is preferred.
• Community Health Worker (CHW) certification preferred.
• CPR/First Aid preferred.

Accommodations

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to talk and hear. The employee frequently is required to stand, walk, sit, and use hands to finger, handle or feel. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, depth perception and ability to adjust focus.

The work environment described here represents those that an employee must meet to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.