Outreach Worker - Care Manager

Summary

The Outreach Worker - Care Manager for Enhanced Care Management (ECM) is responsible for providing high-touch, person-centered care coordination and case management to Medi-Cal members with complex health and social needs, in accordance with California’s CalAIM initiative. This role involves working directly with clients, families, community partners, and healthcare providers to develop and implement individualized care plans that address the physical, behavioral, and social drivers of health.

Essential Functions

• Locates and connects homeless individuals/families on the streets to guide them through the coordinated entry system and/or connect with the Street Health Program and Village Health Center services.
• Works with internal and external parties to provide clients with community resources and aligns clients with resources consistent with insurance benefits to help improve patient health status.
• Collects and enters patient information, status, and statistics for reporting purposes in the electronic health record and various reporting databases to improve efficiency of services.
• Provide frequent outreach, including field visits, home visits, or telephonic engagement as appropriate.
• Records information in electronic medical records, collects and documents patient medical information, including medical history to ensure effective coordination of care.
• Multitasks, communicates with patients, de-escalation & assessment skills, provides customer service and trauma informed care to ensure patient safety and satisfaction.
• Collaborate with interdisciplinary team members, including behavioral health, housing, substance use, and medical providers.
• Schedules patient appointments and maintains communication to confirm future appointments, verifies and/or cancels prescriptions at the pharmacy, and scans and faxes documents.
• Maintains a caseload of clients to assure care continuity and improve stability.
• Provides referrals and case management, documents progress notes, and formulates treatment goals with clients. Monitors client progress and modifies treatment plans as needed. 
• Completes timely clinical documentation and participates in multidisciplinary meetings with internal and external partners. 
• Supports Street Health Outreach Workers, ensuring ECM compliance, and provides training as appropriate to team members.
• Meet productivity and reporting standards by documenting all activities in designated systems.
• Drives street health van to support street health operations and transport patients.
• On time completion of assigned training and policies.
• Performs other duties as assigned.

Qualifications

• High School Diploma or GED
• At least 1 year of outreach and/or enhanced care management experience working with underserved populations. 
• Basic user of MS office
• Participate in annual Tuberculosis screening and/or other screenings when necessary. 
• Reasonable accommodation may be granted where appropriate.
• Possesses a valid California driver's license; and has no Class 1 or more than two Class 2 violations within the past 36 months. 
• Familiarity with CalAIM Populations of Focus (e.g., individuals experiencing homelessness, complex medical/behavioral health conditions).

The Pay Rate for this role is based on several factors including the candidate's experience, qualifications, and internal equity. The initial offer usually falls between the minimum and midpoint of the applicable salary range. Pay Band N4: $23.90 – $31.43 (Midpoint: $26.80)