Care Coordinator – Community Health


As a member of the Community Health Team, the Care Coordinator works with patients and their families/ caregivers to identify their health goals and together with their practitioners create a care plan that will support them in achieving their goals. Responsible for providing care coordination, transitional care interventions and community resource referrals to the patients referred to the Community Health Team (CHT). This position will aim to develop a therapeutic relationship with patients, while assisting them through the process of better health by providing support, encouragement, and education. Must understand family systems, community resources, insurance, regulatory and legal system issues relevant to improved health outcomes for patients.

    1. Coordinates patient care with members of the integrated health care team.
      1. Assesses, within the framework of a holistic approach, the social, emotional, familial, and financial factors impacting the patient/family’s ability to cope with problems of daily living related to their mental health/chronic disease condition.
      2. Reviews completed screening tools to assess and respond to patient needs.
      3. Assesses the patient’s needs and readiness for change using motivational interviewing techniques and builds a therapeutic relationship.
      4. Works with patients to develop a self-management plan for their condition and assists them in achieving their goals.
      5. Provides patient/family educational materials and self-management tools on issues of health maintenance and management of chronic conditions.
      6. Collaborates with cross-departmental teams and/or members of partner agencies (schools, DCF, mental health providers) to develop care plans.
        1. Actively participates in multiorganizational care teams and case reviews to provide patients with wrap-around care coordination through diverse community resources.



    1. Assists patients in securing appropriate services to ensure adequate access to health and human services.
      1. Meets with patients regularly and performs assessments to determine appropriate behavioral health referral.
      2. Provides individual support to coordinate services across providers and sites of care.
      3. Coordinates referrals to other social services agencies as needed, acting as the client’s advocate.
      4. Assists with securing low cost and free medications for patients who qualify.
      5. Assists patients with financial assistance through Sliding Fee applications, hospital financial assistance applications, and insurance applications.
      6. Serves as a resource to staff regarding the resources available to meet social needs of patients.
      7. Informs clients of community services available and make contact with other agencies and community-based organizations on clients’ behalf, as needed to facilitate patient health care needs.
      8. Assures that the necessary communication and information sharing occurs among individuals, families, agencies and providers.


    1. Provides brief mental health support.
      1. For patients with immediate mental health needs, provide resources and coping tools.
      2. Set goals with the patient for obtaining longer-term mental health care and make a referral to a mental health provider.
      3. Conduct CALM as needed for patients with thoughts of self-harm.


    1. Participates in required departmental activities
      1. Attends mandatory staff meetings and committee meetings as deemed appropriate by Director of Community Health Integration.
      2. Completes work assigned accurately and in timely manner.
      3. Demonstrates collegiality and commitment relevant to the mission of Lamoille Health Partners and the CHT.
      4. Maintains absolute confidentiality of all patients’ records, medical treatments, and diagnoses, and abide by all Lamoille Health Partners policies and procedures.



    1. Abides by Lamoille Health Partners’ Compliance Program and Standards of Conduct during term of employment. This is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned as deemed necessary


    1. Education
      1. Bachelor’s degree in Social Work, or related field
      2. LICSW or LMHC preferred
    2. Experience
      1. At least two years of experience in a primary care office, or equivalent in meeting chronic care and mental health needs of patients.
    3. Knowledge and Ability
      1. Must maintain a high level of confidentiality
      2. Strong computer and organizational skills are essential, as well as the ability to multitask, respond to shifting priorities, and to work well under pressure while meeting all required deadlines.
      3. Ability to work independently while demonstrating the skill to work positively within the framework of a team.
    4. Typical Physical Demands
      1. Requires prolonged sitting, some bending, stooping, and stretching.
      2. Requires eye-hand coordination and manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator, and other office equipment.
      3. Requires normal range of hearing and eyesight to record, prepare, and communicate appropriately.
      4. May require occasional lifting up to 25 pounds.
    5. Compliance with HIPAA
      1. Every employee is required to comply with the Health Insurance Portability and Accountability Act (HIPAA) regulations.


  1. WORKING CONDITIONS (Typical working conditions associated with this type of work and environmental hazards, if any, that may be encountered in performing the duties of this position.)
    1. Internal
      1. Work in normally performed in a climate controlled office environment, where exposure to conditions of extreme heat/cold, poor ventilation, fumes and gases is very limited.  Noise level is moderate and includes sounds of normal office equipment (computers, telephones, etc.).   No known environmental hazards are encountered in normal performance of job duties.
    2. External
      1. Work in a community in a variety of settings. Travel is required.


To apply for this job email your details to

Please complete the online forms below.

New patient information form 500.34C Patient Demographic information form 500.34D Medical Record Release of Information form 500.332B2 Health / medical history form Peds 500.34J