Community Network Coordinator

Upward Health is an in-home, multidisciplinary medical group providing 24/7 whole-person care. Our clinical team treats physical, behavioral, and social health needs when and where a patient needs help. Everyone on our team from our doctors, nurses, and Care Specialists to our HR, Technology, and Business Services staff are driven by a desire to improve the lives of our patients. We are able to treat a wide range of needs – everything from addressing poorly controlled blood sugar to combatting anxiety to accessing medically tailored meals – because we know that health requires care for the whole person. It’s no wonder 98% of patients report being fully satisfied with Upward Health!

WHY IS THIS ROLE CRITICAL?

The Community Network Coordinator (CNC) plays an integral role in the Upward Health mission to bring healthcare home, by identifying and connecting our patients to Community-Based Organizations (CBOs). CBOs are generally nonprofit organizations that provide education, vocational education, job training, and other supportive programs to assist individual community members. These organizations tend to focus on individuals with specific needs – education, housing, transportation, food/nutritional support, and more. It is through the connections with these organizations that our patients are often able to address social determinants that impact their overall health. The CNC will establish and maintain ongoing relationships with the area CBOs to ensure the necessary services and supports are offered to individual patients as part of their whole-health journey. The CNC also serves as an advocate for patients, translating the needs and concerns of our patients into action plans that our care team pods can pursue to close support gaps. Our ideal CNC lives within the community our patients reside in and has a deep understanding of the various community supports that are available to our patients. The CNC establishes and maintains ongoing relationships based upon a set of company values and principles, including safety and trust, integrity, quality service and dedication to ensuring patient outcomes by consulting with and supporting all clinical staff in the collective effort to serve our patients.

KEY RESPONSIBILITIES:

• Design a CBO network that can service Upward Health patients and their unique needs – maintaining & updating the list as services are added and/or discontinued.
• Serve as the primary point of contact for community partners that serve in the capacity of community-based organizations.
• Support a unified network of clinical and community partners that shares information for patient care coordination when CBOs are utilized as part of the patient’s needs plans.
• In partnership with clinical and non-clinical staff, monitor the health and needs of patients and help “connect-the-dots” to the most appropriate CBO resources.
• Act as a representative of the community in which our patients reside.
• Advise Providers and non-providers on the CBOs throughout the community – programs offered, hours of service, points of contact, etc.
• Other duties as assigned in support of goals and objectives.

KNOWLEDGE, SKILLS & ABILITIES:

• Interpersonal savvy, demonstrated by the ability to interact with and influence others
• Experience coordinating across teams and external partners to meet individual patient or community member needs
• Experience in social services
• Ability to engage with individuals representing different cultures and backgrounds, adapting language and style as needed
• Excellent written, computer, and oral communication skills – will proactively and thoroughly communicate with other members of the team
• Active listening skills, quick thinking, and able to both be compassionate and respond to objections.
• Strong organizational and presentation skills
• Excellent coordination of multiple schedules and constantly changing demands from various stakeholders

QUALIFICATIONS:

• Must live/reside in the patient service area
• Valid driver’s license and access to a vehicle with current and active insurance
• Deep experience working in and/or with Community-based Organizations
• Able to work flexible hours, including occasional night/weekend work
• Bachelor’s degree preferred
• Ability to travel within patient service area
• Strong communicator, verbal and written, with a deep ability to build trusting relationships

Upward Health is proud to be an equal opportunity/affirmative action employer. We are committed to attracting, retaining, and maximizing the performance of a diverse and inclusive workforce.

This job description is a general outline of duties performed and is not to be misconstrued as encompassing all duties performed within the position.