Social Determinants of Health (SDOH) Care Coordinator Community Resource & Patient Navigation Specialist

Social Determinants of Health (SDOH) Care Coordinator
Community Resource & Patient Navigation Specialist
Position Title
SDOH Care Coordinator – Community Resource & Patient Navigation Specialist

Employment Type
Full-Time

Department
Care Coordination / Patient Support Services

Reports To
Operations Leadership / Care Management Leadership

Company
United Chronic Care Management (UCCM)Attachment.png

Position Overview
United Chronic Care Management (UCCM) is seeking a compassionate, patient-focused, and highly resourceful SDOH Care Coordinator to help seniors overcome barriers that negatively impact their health, stability, and quality of life.

This role is centered around helping patients successfully connect to community resources, assistance programs, social services, and support systems after entering the UCCM program.

The ideal candidate is highly empathetic, organized, persistent, and skilled at guiding patients step-by-step through complicated systems and applications. This individual will serve as a hands-on advocate and navigator for seniors who may struggle with technology, paperwork, phone calls, transportation barriers, or understanding how to access available help.

This role is not simply providing information — it is active patient guidance and real-world assistance.

Core Mission of the Role
To reduce barriers impacting patient health outcomes by personally helping seniors access community resources, support services, and life-improving programs through compassionate navigation and hands-on assistance.

Primary Responsibilities
Patient Resource Navigation
Guide patients through available community and social support resources
Help patients identify needs involving:
Food insecurity
Transportation
Housing instability
Utility assistance
Financial hardship
Medication affordability
Home safety concerns
Caregiver support
Social isolation
Insurance and benefit questions
Educate patients on programs they may qualify for
Hands-On Referral Assistance
Assist patients with completing applications and registrations
Help patients schedule appointments with community agencies
Make outbound calls on behalf of patients when appropriate
Conduct warm handoffs to community organizations and partner agencies
Walk patients step-by-step through next stages of referrals
Ensure patients understand follow-up instructions and requirements
Help patients gather documents needed for assistance programs
Community Resource Coordination
Maintain updated knowledge of:
Local community resources
Senior programs
Nonprofit organizations
Transportation services
Utility assistance programs
Housing support programs
Food assistance resources
State and local benefit programs
Build relationships with community organizations and referral partners
Develop and maintain an internal resource directory for patients
Patient Advocacy & Support
Serve as an advocate for patients experiencing barriers to care
Help reduce patient frustration and confusion during referral processes
Follow up consistently to ensure patients continue progressing
Encourage patients throughout the process and provide reassurance
Help patients remain engaged in supportive services
Documentation & Coordination
Document all patient interactions and resource coordination efforts
Maintain accurate records of referrals and outcomes
Communicate updates to care teams and leadership
Track successful connections to community services
Assist with SDOH-related quality initiatives and reporting
Ideal Candidate Profile
The ideal candidate is:

Compassionate and patient-centered
Comfortable working with seniors
Calm under pressure
Persistent and solution-oriented
Highly organized
Emotionally intelligent
Skilled in communication and active listening
Passionate about helping vulnerable populations
Comfortable guiding patients through difficult situations
Preferred Experience
Healthcare navigation
Care coordination
Social work support
Community outreach
Case management
Patient advocacy
Medicare population support
Call center or telehealth support
Human services or nonprofit experience
Skills & Competencies
Excellent communication skills
Strong empathy and patience
Ability to explain processes clearly
Strong follow-through and accountability
Problem-solving abilities
Ability to multitask and prioritize
Professional phone presence
Ability to build trust with seniors and caregivers
Technology & Systems Experience Preferred
RingCentral
Google Workspace
Microsoft Office
CRM or EHR systems
AdvancedMD familiarity preferred
Online application and benefits portals
Key Success Metrics
Success in this role may be measured by:

Patients successfully connected to resources
Referral completion rates
Patient satisfaction and engagement
Reduction in unresolved social barriers
Timely follow-up completion
Documentation quality
Patient retention and continued program participation
Example Programs & Resources the Coordinator May Help With
Utility assistance programs
Transportation services
Food delivery and nutrition programs
Medication assistance programs
Housing support resources
Senior community programs
Medicaid-related support
Caregiver assistance resources
Home modification assistance
Financial aid programs
State and local aging services
Why This Role Matters
Many seniors qualify for assistance programs but never receive help because the systems are too overwhelming, confusing, or difficult to navigate alone.

This role exists to bridge that gap.

The SDOH Care Coordinator becomes a trusted guide who helps patients move from:

confusion ? clarity
frustration ? support
isolation ? connection
barriers ? solutions
This position directly impacts patient stability, health outcomes, quality of life, and long-term engagement in care.

Executive Recommendation for UCCM
I would strongly recommend eventually building this into an entire:

“Community Resource Navigation Department”
Potential future expansion:

Utility Assistance Team
Transportation Coordination Team
Housing & Benefits Navigation
Senior Advocacy Division
Caregiver Support Services
Community Partnership Development
State Resource Specialists
This type of department can become a major differentiator for UCCM because most organizations only identify problems — very few actually help patients navigate and complete the process successfully.