Client Care Coordinator (Certified Medical Assistant)

• Provide patient education related to overall health, chronic care disease management, medication adherence, lifestyle modification, and follow-up care (under direction of clinical staff)
• Engage patients using culturally responsive, trauma-informed, and health-literacy-appropriate approaches
• Support patients in navigating barriers to care such as transportation, housing instability, insurance challenges, and access to medications

• Serve as a liaison between patients, providers, and support services to ensure timely communication and care coordination
• Assist patients with understanding care instructions, appointment schedules, and next steps in their treatment plans
• Collaborate with case management, housing, and social service teams to address social determinants impacting overall health
• Participate in interdisciplinary team meetings related to chronic care management, and primary and/or specialty care health initiatives
• Support community outreach, education events, and screening initiatives related to overall health
• Contribute to the development and refinement of workflows that promote efficiency, quality, and patient engagement
• Chronic Care Management (CCM) Coordination using best practice workflows
• Identify eligible patients for CCM services and support enrollment, consent, and ongoing participation in accordance with program requirements.
• Coordinate monthly CCM outreach, care plan updates, medication reconciliation support, and interdisciplinary follow-up activities - all of which will be documented in both the EMR as well as internal tracking modules.
• Perform venipuncture and other Medical Assistant duties within scope of practice to support primary and specialty care services.

• Accurately document patient interactions, care coordination activities, CCM services, outreach efforts, and care plans in the electronic health record (EHR), as well as internal tracking modules.
• Track any grant-related data points, outcomes, and activities as required by current grant funded activities
• Assist with reporting, audits, and data collection to support grant monitoring and sustainability efforts

• Strong organizational, communication, and interpersonal skills
• Skill in building rapport with patients, collaborating with providers and interdisciplinary teams, and serving as an effective liaison between stakeholders.
• Ability to work effectively in a fast-paced, integrated clinical setting
• Competence in using electronic health records, scheduling systems, and basic data management tools.
• Ability to assist patients in navigating community supports and healthcare systems, understanding care plans, scheduling appointments, and accessing internal and external services.
• Strong cultural humility and commitment to health equity
• Ability to function as part of an interdisciplinary care team, supporting FQHC providers, clinical leadership, and support service staff.
• Strong ability to manage multiple tasks simultaneously, track follow-up needs, and prioritize responsibilities in a fast-paced clinical environment.
• Ability to effectively support individuals experiencing poverty, housing instability, and other complex social challenges with empathy, professionalism, and respect.
• Understanding of care coordination principles within an integrated healthcare environment, including referrals, follow-up tracking, continuity of care, and interdisciplinary collaboration.
• Knowledge of Chronic Care Management (CCM) workflows, care plan development, patient outreach, and documentation requirements in both an EMR and internal tracking setting.
• Ability to perform venipuncture safely and accurately and support clinical care activities within scope of practice.

Reports to: SVP, Federally Qualified Health Centers

Position Designation: This position is designated as Safety Sensitive. You may be subject to drug testing before or during your employment with SOME. In this position, you may be disqualified from employment based on the presence of marijuana in test results, even if you possess a medical card authorizing the use of medical marijuana.

Physical Demands: Must be able to lift up to 20 pounds. May be required to sit or stand for long periods. Must be able to move around all levels/floors of the building.

To Apply: Go to our career page at https://www.some.org/careers/open-opportunities and click on the search icon to locate this position. Follow the instructions to complete your online application profile to be considered.

SOME, Inc. is a proactive equal-opportunity employer. We ensure that all qualified applicants are considered for employment without discrimination based on race, color, religion, sex, national origin, disability, or protected veteran status.

SOME, Inc. is deeply committed to ensuring the job application process is accessible to all users. If you require assistance or have any concerns about the accessibility of our website or the application process, please feel free to contact us at onlineaccommodations@some.org. This contact information is specifically for accommodation requests and does not pertain to application status inquiries.

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