Service Coordinator I Generalist ECM

Service Coordinator 1 Generalist-Enhanced Care Management (ECM)

REPORTS TO: Program Director

HOURS: 8-4:30pm

CLASSIFICATION:  Non-Exempt

 REQUISITION # 1733

SUMMARY:  

The Enhanced Care Management program is funded through the California Advancing and Innovating Medi-Cal (CalAIM) Initiative and coordinates care by utilizing a person-centered approach to maximizing an individual’s health and life trajectory. ECM services are medically appropriate, and cost-effective alternatives to services covered under the state plan. All potential ECM members must be enrolled in Central California Alliance for Health’s managed care program (MCP). Step Up is a contracted ECM provider and will refer qualified members directly to Step Up’s ECM programs. Step Up will begin outreach and engagement to promote the services, enroll the members in the ECM and provide services intended to improve their social and physical determinants of health. Members remain in the ECM programs until they no longer need or want the services or until their authorizations expire without the possibility of extension/renewal. ECM services consist of a care team providing in-person care management and care coordination that aims to ensure services are available from Managed Care providers for members who are frequent utilizers of health services and individuals experiencing homelessness. The program is designed to leverage existing community care management, housing transition and navigation services, housing tenancy and sustaining services, infrastructure, and experience.

Benefits and What We Offer:

• Opportunities for growth and professional development.
• Generous paid time off (13 paid holidays, 10 days of EPTO, 12 sick days).
• Competitive salary and benefits package. Health, dental, vision, Aflac, and life insurance $25,000.00
• 403(b) retirement plan available on the first day of work. After working 1000 hours, Step Up matches 3% of the 6% the employee contributes.

DUTIES: The following reflects essential functions for this job but does not restrict other tasks, which may be assigned:

Direct Service and Support

• Engage eligible unhoused in Monterey County for necessary ECM services based on need and preference.
• Develop trust and rapport with unhoused individuals throughout Monterey County and serve as a Lead Care Manager for up to 35 clients.
• Embody Step Up’s Core Values of Hope, Wellness, Respect, Voice and Choice and Collaborative Relationships while working with members and colleagues and articulate understanding of how the values show up in practice.
• Assess members’ understanding of programs and ensure informed consent is provided prior to referral.
• Demonstrate cultural competency by sharing important nuances and strengths across Monterey County communities and how they may impact individual service provision. 
• Interface with local systems involved in member care such as Clinica De Salud, Monterey Transit Center, Catholic Charities, Community Human Services, County Behavioral Health, Doctors on Duty, California Rural Legal Assistance, Central California Alliance for Health, Monterey County Office of Education, Central Coast Overdose Prevention, Valley Health Centers and more.
• Complete Healthcare Assessment, client intake packet, Pain and Nutrition Screening and Individualized Service Plan within one month of client enrollment.
• Complete monthly billable case notes in a member’s electronic health record and ensure they are written in the correct format.
• Facilitate appropriate triage and linkage services for ECM members to help resolve homelessness and improve health outcomes.
• Help develop individualized service plans for all clients enrolled in ECM that outline tangible member goals with concrete action steps.
• Support teammates and colleagues in understanding programmatic differences between ECM and CS and successfully communicating program specifics to prospective clients.
• Travel throughout Monterey County and provide in-person outreach services to members eligible for ECM.
• Evaluate immediate needs such as crisis intervention/prevention, medical attention, showers, food, clothing and hygiene and respond and document accordingly.
• Utilize Motivational Interviewing skills to reflect client ambivalence while guiding clients toward change
• Support colleagues with initial onboarding processes for ECM programs, including establishing consent via ROI, submitting proper referrals, documenting outreach attempts, and initiating care plans/housing plans.
• Coordinate services with local medical teams, mental health teams, and schools,
• Work with families and youth and understand key distinctions between family/youth homeless service provision and adult homeless service provision.
• Manage and track client referrals to ensure services are rendered and follow up is provided withing CCAH recommended timelines.

Documentation and Data Collection

• Successfully screen clients into Step Up’s internal EHR and complete necessary intake
• Support staff with best intake and referral practices and help develop workflows that support member driven services and efficiency.
• Ensure that client care plans are expediently completed to meet CCHA timelines without sacrificing person-centered approach to care.
• Document all outreach attempts and successful engagements for ECM in EHR.
• Complete Comprehensive Health Assessment (HA) and Pain and Nutrition Screening assessment to help inform ECM service plans.

Skills:

• Knowledge of mainstream benefits and services competencies such as Critical Time Intervention, Motivational Interviewing, Trauma Informed Care, Housing First, Harm Reduction, etc.
• Ability to work collaboratively with others and in a team. Initiative and solution focused practice
• Uses good time management skills and resources to balance case load direct service and paperwork
• Ability to work as a team member on the streets, in homeless facilities or with other homeless community providers such as police, hospitals, and social services.
• Ability to engage individuals on the streets in a meaningful manner that creates trust and increases optimism
• Understands and promotes safety first to self and team members

QUALIFICATIONS: 

• Bachelors Degree preferred, plus 2 years of related work experience working with homeless population, in a social service field, or volunteer position. 
• Case management experience is required, including the ability to sensitively assess client needs and strengths, and chart patient progress to meet documentation requirements. 
• Candidate must have own transportation and current California driver's license and insurance and will be required to drive to and from engagement points, events, etc. 
• Position requires occasional transporting of members.

SUPPLEMENTAL INFORMATION: 

Work with people experiencing homelessness whether on the streets, in shelters or other places of habitation or services, may present inherent challenges and difficulties such as: exposure to bed bugs or other infestations, unpleasant smells or odors, individuals who may have poor hygiene or unclean homes due to homelessness, mental health symptoms, or poverty.   Additionally, in working with our members, employees may encounter instances of profanity, sexually explicit or derogatory language, or verbal or physical expressions of anger and trauma. Very rarely do these situations ever escalate to physical contact, and negative or derogatory communication patterns can often be negotiated successfully.   All direct care staff are provided adequate training to develop skills to deescalate crisis situations that may arise and Step Up has established procedural safeguards for all employees to mitigate (but not eliminate) these inherent risks of employment.

PHYSICAL REQUIREMENTS: 

While performing the duties of this job, the employee is regularly required to sit; use hands and fingers; handle or feel; reach with hands and arms; talk; and hear.  The employee is frequently required to walk, balance, stoop, kneel, and/or crouch. The employee must occasionally lift and/or move up to 15 pounds.  Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and ability to adjust focus.  Keyboard data entry required.

Step Up utilizes the principles of trauma-informed care and mental health recovery. These principles inform our Core Values of Hope, Wellness, Voice and Choice, Respect, and Collaborative Relationships. As representatives of Step Up, employees agree to adhere to these values in their interactions with members, colleagues, supervisors, and associated community members.

STEP UP CORE VALUES

HOPE – We believe all people have the capacity for positive growth and change. We use hope to inspire and motivate ourselves, our members, our colleagues, and our community.

WELLNESS – We believe in promoting a culture that supports healthy and fulfilling lives. We use a supportive environment to foster well-being for ourselves, our members, our colleagues, and our community.

VOICE AND CHOICE – We believe in the right to choose and be heard. We use voice and choice to create meaningful outcomes and empowerment for ourselves, our members, our colleagues, and our community.

RESPECT – We believe in promoting interactions that are non-judgmental and transparent. We use respect to guide all of our words and actions with ourselves, our members, our colleagues, and our community.

COLLABORATIVE RELATIONSHIPS – We believe in forming partnerships to share resources, knowledge, and experiences. We use collaborative relationships to strengthen accomplishments for ourselves, our members, our colleagues, and our community.

Step Up is committed to providing quality services that adhere to the highest ethical standards and principles. All Step-Up employees agree to adhere to the ethical policies and codes of conduct, as outlined in the Employee Handbook and those specified for this grant.

Step Up provides equal employment opportunities without regard to age, ancestry, color, creed, mental or physical disability, marital status, medical condition, national origin, race, religion, sex, sexual orientation, veteran status, or any other consideration made unlawful by federal, state, or local laws.

STEP UP IS AN EQUAL OPPORTUNITY EMPLOYER