People's Center Clinics & Services logo

Company Profile

Minneapolis, Minnesota
United States

Job Profile

Job Category:
Education - Training, Health Care - Medical, Non-Profit
Position type:
Full Time
Zip Code:
Reference number:
Job Id #:
Date Posted:
December 04, 2018

Care Coordinator, Bilingual

 Bilingual in Somali

People’s Center Clinics & Services (PCCS) is a nationally recognized community health center delivering high-quality, affordable, and culturally relevant care to everyone, regardless of their ability to pay. For 50 years, People’s Center has stood as a beacon of hope in the global village of Cedar-Riverside in South Minneapolis - a neighborhood that has long been the first stop for new Americans. PCCS’ mission is to deliver affordable healthcare, inspire hope, and promote community wellness.


The  Care Coordinator collaborates with primary care physicians, clinic staff and other Health Care Home team members to identify needs, organize activities, and coordinate plans of care for patients with chronic conditions. The care coordinator is an advocate for the patient and works to link them with health and community services that provide a range of services, promote self-management, improve health and reduce disparity. The care coordinator assists patients to achieve health goals and improved health care outcomes. One of the main challenges of this position is working with multiple providers, staff and collaborative partners with differing needs and opinions to improve the care to typically diverse and underserved people. Normal working hours are Monday – Friday from 8:30 AM to 5:00 PM. 


Assess the Health Status of Patients

  • Reviews referrals and works with medical providers to identify patients who qualify for health care home participation in Tiers 2-4 (per policy).
  • Conducts an initial patient assessment including a PHQ-9, Patient Perception Survey, review of medications, lab and other test results, review of clinic scheduling policies, and review of Health Care Home program objectives.
  • Accurately completes and documents patient health information and problems in the  electronic health records (EMR) system, and enrolls patients in the Health Care Home (using the appropriate diagnosis code (e.g. V72.85C); HCH Patient Encounter) changing the problem list display name to read “Health Care Home”.
  • Collaborates with nursing staff to assess and determine the applicable MDH chronic conditions Tier selection.
  • Plans, coordinates and provides patient-specific health education based on the chronic or associated conditions identified.
  • Determine and advise patients on other potential services the patient may want/need.
  • Serves as an advocate for the patient to understand needs (i.e. shelter, transportation, child care, safety) and refer to the behavioral health services.
  • Discusses end-of-life situations, if applicable, and health care directives with patients and coordinates these activities with other Care Team members.
  • Informs patients who are uninsured if there is a charge/minimum fee for health care home (non-billable) visits.
  • Discuss with patient and update primary care provider (PCP) in the EMR if applicable.

Develop and Maintain a Care Plan

  • Works with the patient, providers, and HCH Care Team members to develop and maintain an individualized clinical Care Plan for the patient. (See Care Plan Policy)
  • Collaborates with the provider and HCH Care Team to ensure Care Plan data is up-to-date and complete.
  • Assists patients with the identification, selection, monitoring and documentation of self-management goals. 
  • Follows up with the patient to ensure the patient’s responsibilities are being followed and met. Monitors the patient’s progress toward goal achievement and modifies as needed.
  • Schedules follow-up appointments at CRPC 30 days after enrolment or calls patients to ensure the patients are getting the services they need, outcomes are improving, and determine if progress is being made towards defined goals. 

Care Management

  • Follows the prescribed care coordination workflow to comply with health care home certification requirements.
  • Interacts and coordinates care with team members and providers, including clinic such as, social workers, pharmacist and nutritionist to ensure comprehensive care for the patient.
  • Identifies clinic and community resources and coordinates appropriate referrals.
  • Conducts follow-up PHQ-9 questionnaire if applicable and responds accordingly.
  • Collaborates with the clinical staff for pre-visit planning for annual checkups/physicals
  • Works with the clinic front desk staff to schedule applicable clinic appointments.
  • Conducts regular, periodic care plan review with the patient and/or family.
  • Arranges for interpreter services if needed.
  • Reviews HCH patient’s records to determine when patients should be seen by their primary care provider for any one or more of their applicable chronic conditions and works with the patient to schedule an appointment.
  • Notifies the primary care provider if patients decline or choose to leave the program. Keep the provider informed on HCH progress via Epic documentation-only encounter.
  • Use the HCH patient registry, a virtual list based on a specific HCH diagnosis code or other designation, to create lists of HCH participants based on variable selection criteria.
  • The Care Coordinator has interaction with many people/departments within the clinic’s Health Care Home environment. The Care Coordinator has authority to revise protocols and workflows to ensure compliance with HCH requirements.


  • Three to five years of experience in a health care setting, preferably primary care,  and working with underserved and at-risk populations.
  • Ability to work both independently and collaboratively as an effective member of a health care team.
  • Proven strong interpersonal skills.
  • Ability to work comfortably at a computer for long periods of time
  • Women’s Health experiences a plus.
  • 3-5 years’ experience as a medical interpreter or community health worker 
  • Experience working with culturally diverse and low-income populations.
  • Associate degree or Bachelor’s degree preferred



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