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Why M Physicians M Health Fairview Clinic - Phalen Village is a conveniently located neighborhood clinic on Maryland Avenue in St. Paul that offers comprehensive care for your entire family, through all stages of life. We make everyday care for kids and adults easy, from annual checkups, vaccinations, and sports physicals to treatment for common illnesses, mental health care, women's health care, and more. For extra convenience, we offer onsite lab services for diagnostic testing or health screening. M Health Fairview is dedicated to comprehensive, personalized primary care for the whole person and the whole family. If you or your child ever needs specialty care for a serious illness or complex condition, our primary care team can easily refer you to specialty care experts at our network of nearby community hospitals, our flagship academic medical center in Minneapolis, or our dedicated children's hospital. What you will do as a Care Coordinator: Serves as a single point of contact by facilitating and coordinating transitions in care within and between care settings, providers, and services Completes pre-visit planning and post-visit wrap-up and determines vital follow-up appointments and/or treatments to optimize patient visits Facilitates proactive disease management and preventative health care using evidence-based practice Works with the clinic's health care team to provide direct patient care through assessment and referrals to appropriate community, governmental, or social service programs Engages in population health strategies and participates in panel management Completes the Care Coordination process for clinic team's patients including: Referrals, hospital discharge coordination, working with providers to complete Care Plans as necessary, creating goals with patients and follow-up with the patients on goal setting and other duties for care coordination Advocates for patients by evaluating obstacles to medical care at the clinic Works with PCS, Physicians and other staff in the health care home environment to remove any barriers to receiving excellent, cost effective care Collaborates with, and delivers information to appropriate community organizations Participates in the development and implementation of policies and procedures for the Social Worker position working in the health care home setting Participates in faculty, resident and new employee orientation/education Demonstrates ability to deliver care or service adjusting approaches to reflect developmental level of population served What you will need: RN Current Minnesota RN license BLS certification Demonstrated experience in patient advocacy and education, coaching, and proactive health care management along with EMR/digital literacy OR Social Worker Bachelor's degree in Social Work required Minnesota Social Work licensure required 2-4 years of experience in Social Work within healthcare setting Location: 1414 Maryland Ave E, Saint Paul, MN 55106 Hours: 1.0 FTE Benefits: This is a fully benefit eligible position: Competitive wages, Healthcare (including vision & dental), 401K, parking & tuition assistance and more! #RN University of Minnesota Physicians (M Physicians), a non-profit organization headquartered in Minneapolis, seeks motivated individuals for both clinical and non-clinical roles to drive innovation in health and medicine. Our inclusive culture offers competitive salaries, excellent benefits, and the opportunity for career development in the exciting field of health care to over 1,200 physicians, 300 advanced practice providers, and 2,200 health professionals and staff across Minnesota and beyond. Join us on a mission to advance medicine. We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, sex, gender, gender expression, sexual orientation, age, marital status, veteran status, or disability status. We will ensure that individuals with disabilitie are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. UMPhysicians is an Equal Opportunity/Affirmative Action/Military Friendly employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex, national origin, sexual orientation, age, marital status, status with regard to public assistance, disability, or status as a protected veteran.