Location: Indiana (Remote)Schedule: Full-Time, Monday–Friday

Work Environment: Remote/Home-Based
Position Summary:

• The Community Well Coordinator serves as a trusted partner to members with complex medical, behavioral health, and social needs. This role supports individuals in achieving their health and wellness goals through comprehensive assessments, individualized care planning, resource coordination, and ongoing engagement.
• Working closely with healthcare providers, community organizations, and interdisciplinary care teams, the Community Well Coordinator helps members navigate healthcare services, address barriers to care, and access resources that promote improved health outcomes, independence, and overall well-being.
• The ideal candidate is passionate about supporting vulnerable populations, skilled in building meaningful relationships, and committed to delivering person-centered, culturally responsive care.

Key Responsibilities:

• Member Assessment & Engagement
• Conduct telephonic assessments to evaluate members’ medical, behavioral, functional, cultural, and socioeconomic needs, including Social Determinants of Health (SDOH).
• Build trusting relationships with members and actively engage them in their healthcare journey.
• Identify strengths, barriers, and opportunities that may impact health outcomes and quality of life.
• Utilize motivational interviewing and person-centered communication techniques to support member engagement and self-management.
• Individualized Care Planning
• Develop and implement comprehensive, person-centered wellness plans based on each member’s goals, preferences, needs, and readiness for change.
• Collaborate with members to establish realistic and meaningful health and wellness goals.
• Monitor progress toward goals and adjust wellness plans as needed to support positive outcomes.
• Encourage member participation in decision-making and self-directed care planning.
• Resource Coordination & Support
• Connect members with healthcare services, behavioral health resources, and community-based programs that support overall well-being.
• Facilitate referrals and linkages to internal and external resources, including:
• Primary care providers and specialists
• Behavioral health services
• Medication-assisted treatment programs
• Housing and social support services
• Pharmacy and medication resources
• Peer support programs
• Community organizations and local assistance programs
• Assist members in overcoming barriers related to transportation, housing, food access, financial concerns, and other social needs.
• Collaboration & Care Coordination
• Partner with interdisciplinary care teams, healthcare providers, caregivers, and community organizations to support implementation of wellness plans.
• Participate in case consultations and team discussions to ensure coordinated and effective member support.
• Maintain timely and accurate documentation of assessments, interventions, referrals, and member interactions.
• Promote continuity of care during transitions between healthcare settings and services.
• Advocacy & Education
• Educate members regarding available benefits, healthcare services, community resources, and wellness opportunities.
• Empower members to make informed decisions about their health and care options.
• Advocate for member needs while promoting independence, self-advocacy, and personal accountability.
• Support health literacy and encourage preventive care and healthy lifestyle practices.

Required Qualifications

• Candidates must meet one of the following education and experience requirements:
• Education & Experience
• Bachelor's degree in Social Work, Psychology, Counseling, Gerontology, Health & Human Services, or a related field;
• OR Bachelor's degree in any field and at least two (2) years of full-time direct service experience working with older adults or individuals with disabilities, including assessment, care planning, and monitoring;
• OR Associate degree in any field and at least four (4) years of full-time direct service experience working with older adults or individuals with disabilities, including assessment, care planning, and monitoring.
• Additional Requirements
• Minimum of two (2) years of experience supporting older adults, individuals with disabilities, or participants receiving
• Long-Term Services and Supports (LTSS).
• Minimum of one (1) year of experience utilizing Microsoft
• Office applications, including Word, Excel, and Outlook.
• Must reside in the state of Indiana.
• Ability to work remotely from a private, secure home office environment that protects Protected Health Information (PHI).
• Reliable high-speed internet access that meets organizational requirements.
• Strong communication, organization, and relationship-building skills.

RepuCare is a certified woman-owned business with more than 30 years of experience delivering high-quality healthcare and professional staffing solutions. We are committed to operational excellence and improving outcomes through compassionate, compliant, and client-focused services.