Access to Care Coordinator

Job Summary

The Access to Care Coordinator serves as a vital member of the maternal and infant health team, working in close collaboration with the Maternal Health Specialist to improve health outcomes for pregnant and postpartum individuals and their infants. While the Maternal Health Specialist focuses primarily on clinical assessment, education, and healthcare management, the Access to Care Coordinator focuses on reducing barriers to care, addressing social determinants of health, facilitating access to community resources, and supporting appointment adherence. This role provides intensive care coordination and patient navigation services for individuals identified as having elevated risk factors for adverse maternal or infant outcomes. The coordinator proactively engages patients, assesses patient needs, develops individualized support plans, and ensures patients have the resources necessary to access recommended care throughout pregnancy and the postpartum period.

Essential Job Duties

• Conduct comprehensive assessments of barriers that may impact access to care and health outcomes.
• Coordinate services and support for pregnant and postpartum patients identified as high-risk due to social, economic, environmental, or behavioral factors.
• Assist patients in developing personalized action plans to address barriers to care.
• Monitor patient progress and maintain frequent contact through phone calls, text messages, telehealth platforms, or in-person interactions as appropriate.
• Collaborate closely with Maternal Health Specialists to ensure seamless coordination between clinical and non-clinical interventions.
• Ensure timely follow-up after missed appointments, emergency department visits, hospitalizations, or other high-risk events.
• Develop collaborative relationships with community agencies, public health organizations, transportation services, housing programs, nutrition assistance programs, and other support networks.
• Participate in outreach initiatives to increase awareness of maternal and infant health resources.
• Assist in identifying service gaps and opportunities to improve access to care for vulnerable populations.
• Track patient engagement, referral completion, appointment adherence, and care coordination outcomes.
• Assist with program evaluation and performance improvement initiatives.
• Participate in quality improvement efforts aimed at reducing maternal and infant morbidity and mortality.
• Maintain compliance with organizational policies, confidentiality requirements, and applicable regulatory standards.

Position Disclosures

This position is funded through an external grant and is contingent upon continued grant funding. The Access to Care Coordinator is expected to understand and support the goals, objectives, and performance measures outlined within the grant program. The coordinator will play a key role in ensuring program activities align with grant requirements and contribute to the achievement of established outcomes related to maternal and infant health. This Rural Health Transformation Program is supported by the Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $206,927,896.80 with 100 percent funded by CMS/HHS.

Qualifications

Education: Associate's degree required; Bachelor's degree in Social Work, Public Health, Human Services, Nursing, Community Health, Psychology, or a related field preferred.

Experience: Minimum of two years of experience in care coordination, case management, patient navigation, community health, social services, maternal health, or a related field preferred. Experience working with vulnerable or underserved populations strongly preferred. Experience addressing social determinants of health and connecting patients with community resources preferred.