Principal Duties and Responsibilities

Under the CalAIM ECM (Enhanced Care Management) program and the general supervision of the Director Strategic Programs and Development, the ECM Care Coordinator provides direct services and care management support as well as participates in part of the multidisciplinary care team for ECM clients. The Enhanced Care Coordinator has a caseload of eligible ECM participants, many of which are individuals experiencing homelessness and is responsible for conducting outreach, enrollment, coordinating health care services, provides education and supports member access to care in a timely and cost-effective manner.

The Care Coordinator works alongside their clients, establishing strong communication and collaboration in their plan of care, as well as works with caregivers/family members and other support persons, and providers in an effort to promote wellness, independence, resilience, and empowerment, while ensuring access to appropriate resources and services and maximizing benefits. The Care Coordinator will also serve as a clinical advocate for clients, participate on a regular basis in a multidisciplinary team setting, and act as a liaison for external health and social service providers throughout the community.

Responsibilities:

Day-to-day responsibilities include, but are not limited to, all the essential functions listed below:

• Assess member needs in the areas of physical health; mental health; oral health; palliative care; memory care; trauma- informed care; social supports; housing; vocational/employment; wellness; and referral and linkage to community-based "longer" term services and supports.

• Provide/arrange services based on the personalized care plan for each client. Examples include, but are not limited to: assisting the client in applying for publicly funded/provided services, providing advocacy, transportation, mental health promotion, and mentoring to maximize benefits to the client for programs such as IHSS, Medi-Cal, HMO’s, etc.

• Conduct initial and ongoing outreach, information and referral services to incoming clients who are referred by the Managed Care Plan to facilitate linkage to the ECM program including but not limited to phone calls, mailed information, and field visits.

• Implement all aspects of care management activities, according to agency policy, including in-home assessment; client records; information & referral; case monitoring; counseling, and individualized care plans.

• Offer services where the member resides, seeks care, or finds most easily accessible, including office-based, telehealth, or field-based services.

• Provide appropriate crisis intervention to both care management clients and the community at large.

• Interview clients to assess how best to coordinate the delivery of requested services.

• Work collaboratively with hospital staff and skilled nursing facilities regarding Discharge Planning.

• Accompany members to office visits, as needed and appropriate.

• Evaluate progress and update goals on a regular basis

• Complete all documentation, including Outcome Measures within the timeframes established by the individual plans and the Center.

• Maintain up-to-date documentation and billing for each client served.

• Actively link and refer clients to appropriate community resources.

• Making an effort to build a relationship of trust with the client.

• Utilize "evidence-based" practices, such as Motivational Interviewing, Stages of Change, Harm Reduction Techniques and Trauma- Informed Care principles.

• Actively participate as a member of a Multidisciplinary ECM team and advocate on behalf of your assigned clients.

• Remain up to date on new resources, referrals, etc. by attending regular trainings in specified service area.

• Maintain ongoing communication with supervisor and attend telephone supervision and monthly or bi-monthly in person supervision.

• Maintains a safe work environment: Implements, reviews, applies and actively enforces the clinic’s safety policies.

• Knowledgeable of and compliant with laws and regulations governing area of responsibility.

Skills/Qualifications:

• Skill in exercising a high degree of initiative, judgment and discretion.

• Skill in analyzing situations accurately and taking action.

• Skill in establishing and maintaining effective working relationships.

• Skill in organizing work, delegating and achieving goals and objectives.

• Skill in exercising judgment and discretion in developing, interpreting and implementing departmental policies and procedures.

• Ability to plan, organize and integrate priorities and deadlines.

• Ability to evaluate and make recommendations for continuous quality improvement.

Education and Experience:

• Paraprofessional

• 2 years or more of experience providing case management services for vulnerable and/or underserved and diverse populations, preferably with individuals experiencing homelessness.

• Must act in accordance with all Health Insurance Portability and Accountability Act (HIPAA) requirements.

• Competent in Microsoft Office suite (Word, Excel, PowerPoint).

• Bilingual ability is preferred but not required.

Physical Requirements:

The physical demand described here are representative of those that must be met by an employee to successfully perform the essential functions this job. Reasonable accommodations may be made to enable individuals with disabilities with disabilities to perform the essential functions.

• TB Clearance

• COVID-19 Vaccines

• Valid California driver’s license

• Must have reliable transportation with minimum insurance/liability coverage

• Sits, stands, and walks intermittently throughout the day.

• Regularly required to talk and listen to others in person and over the phone.

• Occasionally required to climb, stoop, bend, keel, crouch, and reach above shoulders

Job Type: Full-time

Pay: $25.00 - $30.00 per hour

Expected hours: 40 per week

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee discount
• Health insurance
• Life insurance
• Paid sick time
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Work setting:

• Clinic
• In-person
• Office
• Outpatient

Ability to Relocate:

• Anaheim, CA 92801: Relocate before starting work (Required)

Work Location: In person