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Social Determinants of Health Coordinator






Raleigh, North Carolina • Wake County

Date Needed:

October 02, 2020

Organization Website:

Type Of Position:

Full Time

Education Required:


Experience Required:

3-5 year(s)

Date Of Job Posting:

September 14, 2020

Job Description:

Primary Purpose
The Social Determinants of Health (SDoH) Coordinator will focus on NCCHCA’s contract with the state’s Clinical and Community Connections for Prevention and Health (CCCPH). The coordinator will define and organize current work around social determinants, patient complexity, population segmentation and programming that assesses and responds to this arena. This position will facilitate and encourage the conversations and interventions needed to create health equity for all through a root cause focus. 

Essential Duties and Responsibilities

§  Stays apprised of Current SDoH Efforts: Catalogs tools, studies current workflow, engages CHCs, and interacts with SDoH-focused and community-based partners, mapping and aligning current SDoH efforts (NCCHCA, CMHN HCCN, FQHCs, and beyond). Collects data and information around tracking enabling services, social determinant tools and interventions, and approaches to measuring the impact of SDoH-focused efforts. Marshals arguments and evidence to support upstream investments. Engages in on-site observation, interviews, and/or focus groups of workflows and processes for data collection and “treatment” of upstream issues.

§  Monitors and Advances Community Partnerships Around SDoH Activities: Interacts with NC FQHCs and catalogs current interventions as well as populations served, and areas of interest for future SDoH work. Facilitates community partnerships on behalf of the Association, including but not limited to tracking statewide, regional, and national SDoH activities. Leads/facilitates conversations with NCCHCA staff and partners to refine/redefine interviewing and data collection tools that will be used to improve CHC programs that address social determinants of health, measure their effectiveness and develop a case for payers to invest in these services. Partners with state and national groups to further the abilities of CHCs and NCCHCA to move care upstream. Maintains strong communication and collaboration with the full NCCHCA team regarding PCMH and HRSA and their evolution to effectively address the SDoH.

§  Identifies Gaps in SDoH Initiatives and Develops Strategy: Identifies gaps in information to further NCCHCA’s SDoH initiatives. In partnership with the NCCHCA SDoH internal team, facilitates the development of a “roadmap” as to the best course to spread SDoH work from concepts to action to health improvement to payment structures supportive of health and wellbeing.

§  Implementation and Sharing: Develops toolkit and/or other content to support FQHCs in developing partnerships with community-based non-medical organizations, to support addressing identified SDoH needs. Supports the implementation of tools, tracking, reporting, sharing learning widely, and new partnerships/workflows that attend to the root causes of poor health.

§   Provides Technical Assistance and Coaching: Provides technical assistance to CHCs wishing to implement SDoH-related programs. Augments ways to share data to foster ongoing improvement. Assists/coaches, in tandem with NCCHCA team, FQHCs in interviewing around SDoH and creating actionable responses to patient priorities.

§  Develops and Leads Trainings on SDoH: Coordinates SDoH-focused topics and learning opportunities at peer network gatherings. Works with TA team to develop and offer training events/onsite training for CHC staff, board members and a variety of stakeholders around workflows for tracking and improvement of social determinants.



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