Support Better Health Outcomes—Join Southside Community Health Services as a Chronic Condition Outreach Coordinator

Southside Community Health Services (SCHS) is a full-service, non-profit healthcare clinic serving the South Minneapolis community. We are committed to improving the health of our patients and communities by delivering exceptional care, removing barriers, and promoting healthy lifestyles.

About the Role

The Chronic Condition Outreach Coordinator supports patients managing chronic conditions such as diabetes, hypertension, and chronic kidney disease. Working closely with the Chronic Condition Care Team, this position helps connect patients to care, close care gaps, coordinate resources, support health education programs, and improve patient outcomes and satisfaction.

Key Responsibilities

Conduct daily patient outreach to schedule appointments, connect patients with care team members, and support closure of chronic condition care gaps
Manage internal referrals to Chronic Condition Care Managers, Diabetes Self-Management Education (DSME), and other chronic condition programs
Complete Social Determinants of Health (SDOH) screenings and connect patients with appropriate resources and support
Coordinate referrals and connections to Oral Health, Vision, Patient Advocate, and Behavioral Health services as appropriate
Recruit patients and support cooking, nutrition, and other chronic condition education programs, including occasional evening events
Maintain program tracking logs, inventory, educational materials, and quantitative data needed for grant reporting
Create and distribute patient education materials and program communications in collaboration with the chronic condition care team
Respond to EPIC messages, phone calls, and emails from patients and staff in a timely manner
Support staff communication, education, and implementation of new clinical policies and procedures
Participate in committees, staff and program meetings, Health Care Home activities, conferences, and other community health initiatives
Collaborate with interdisciplinary teams to support integrated, patient-centered care

What You Bring

Commitment to continuous improvement and the SCHS mission and staff values
Strong organizational, time management, recordkeeping, and reporting skills
Excellent communication and interpersonal skills with the ability to work across multiple disciplines
Ability to work independently while contributing effectively to a collaborative team
Professional judgment, attention to detail, and flexibility in an evolving healthcare environment
Ability to build rapport with patients and colleagues from diverse cultural and socioeconomic backgrounds
Knowledge of the healthcare environment, particularly Federally Qualified Health Centers

Qualifications

EPIC experience
Minimum of two years' experience in a healthcare setting.
Minimum of two years' experience direct customer service.
Strong office and administrative skills to include MS Office and other statistical programs.
Have reliable transportation, valid driver's license, and car insurance.
Flexibility to work nights, if needed, during reporting season and for special patient centered events and programming
Fluency (written and verbal) in English and Spanish preferred.

CHW jobs

Chronic Condition Outreach Coordinator