Careers At Legacy Community Health Services

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Clinical Integration Coordinator

Department: Clinical OB
Location: Houston, TX

Legacy Community Health is a premium, Federally Qualified Health Center (FQHC) that provides comprehensive care to community members regardless of their ability to pay. Our goal is to treat the entire patient while improving their overall wellness and quality of life, in addition to providing free pregnancy tests, HIV/AIDS screening. At Legacy, we empower patients to lead better lives by promoting healthy behaviors and offering resources such as literacy classes, family planning services, and nutrition and weight management information.

Our roots began in 1981 as the Montrose Clinic, with specialization in HIV education, testing, and treatment. Since then, the agency has expanded to 10 clinics in Houston, one in Baytown, two in Beaumont, and one in Deer Park with extensive services that include: Adult primary care, HIV/AIDS care, pediatrics, OB/GYN and maternity, dental, vision and behavioral health. We also service students within KIPP and YES Prep schools. Legacy is committed to driving healthy change in our communities.

Job Description

The position serves to support the activities for improving activities and services to support clinical integration, patient care and improved outcomes.  The position serves to support the activities for improving activities and services to support clinical integration, patient care and improved outcomes. 

Essential Functions

  • Work in collaboration with clinical leadership and other clinical team members to enhance innovative and evidence-based care.
  • Actively participate in closing gaps in care as determined by the reporting provided by the managed care providers.
  • Works with patients to identify barriers to obtaining medications and taking medication
  • Identifies patient needs post discharge from the hospital and coordinates an appointment with appropriate providers, including but not limited to a primary care physician.
  • Based on a report, reaches out to patients who require an annual visit to coordinate that care in person or via Telemed.
  • Coordinates further appointments and sends appropriate testing to patient to support breast and colon cancer screening.
  • Gathers data to present ideas for further opportunities to improve documentation and follow-up.
  • Upon discussion with patients, review and update list of active medical conditions and educates patients about self-management tasks they can undertake to gain greater control of their health status.
  • Refers patients to other entities for education as needed.
  • Assist patients with procurement of medical supplies needed to care for themselves when necessary.
  • Contacts patients between visits via telephone, email, or other means to check on self-monitoring, provide encouragement and support, and assess patient progress toward health status goals.
  • Performs other duties as assigned.

Education & Training Requirements

  • Medical Assistant Certification or LVN required
  • High School Diploma or GED required

Work Experience

  • Minimum 7 years’ experience in a healthcare setting required
  • Experience in provision of Primary Care preferred
  • Supports practice mission and goals
  • Must be able to manage multiple deadlines and prioritize
  • Bilingual Spanish preferred


  • 9 Holiday + 1 Floating Holiday
  • PTO
  • 403b Retirement Plan
  • Medical / Vision / Dental (if eligible)

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