Roots Community Health Center Jobs Hiring Now

Position Summary:

Representing Roots Community Health Center as a dedicated member of the Clinical Programs team, the Clinical Programs Specialist (Diabetes Management Focus) drives care coordination, patient education, and proactive outreach primarily for individuals living with Diabetes. While this role occasionally supports cross-functional clinical initiatives, the primary purpose is to improve health outcomes for our diabetes patient population.

The Clinical Programs Specialist provides superior patient service, collaborating closely with care teams, clinic personnel, external specialty providers, and community partners. Managing a large patient panel, you will use advanced prioritization skills to proactively track and coordinate diabetes clinic visits, laboratory monitoring (e.g., A1C tracking), specialty referrals (podiatry, ophthalmology), and community-based outreach. This position monitors, communicates, and documents all patient interactions across multiple tracking systems and Electronic Health Records (EHR) to ensure compliance with quality reporting requirements and deliver timely, impactful care.

Duties and Responsibilities:

• Conduct outreach to increase awareness of clinical programs in the community and to partner organizations.
• Conduct "in-reach" to current patients and members to increase engagement in clinical programs.
• Collaborate with patients' navigation team members to coordinate care and share patient progress.
• Maintain up-to-date and accurate service information in program-specific patient tracking systems on a daily basis.
• Support group visits or activities and assist with the distribution of incentives to program participants.
• Work with the patient’s care providers to support the patient in recommended visit schedules.
• Outreach to patients to educate them about clinical programs under the direction of the Clinical Programs Manager.
• Work with Administrative staff to ensure accurate documentation and reporting.
• Outreach and promote Roots events, campaigns, and classes.
• Provide relevant information to the team to support the strategic development of the programs.
• Attend regular program meetings to discuss the status of service coordination, challenges/barriers to conducting the work, including hard-to-reach patients or workload.
• Identify and report issues that require escalation to the next level of management for resolution.
• Willingness to shift to new processes, projects, etc. as needed.
• Attend and participate in MAA Implementation Trainings.
• Back up or coordinate with Patient Care Coordination staff to verify insurance, referrals, and appointment scheduling.
• Attend organizational and other training and meetings related to the job role.
• Must be able to work on-site full-time.

Competencies:

• 1 year experience performing clinical, coordination, and/or administrative functions preferred.
• Strong interest in healthcare, social determinants of health, and health disparities.
• Interest/experience working with low-income communities of color.
• Excellent written and verbal communication skills.
• Excellent team-player.
• Ability to manage multiple phone lines, spreadsheets, and files.
• Ability to work with patients from different backgrounds.
• Strong working knowledge of Microsoft Office and G-Suite.
• Ability/willingness to learn Electronic Health Records and multiple reporting systems.