Care Coordinator - Enhanced Care Management

Neighborhood Healthcare•Riverside, CA

13d•$23 - $28•Hybrid

About The Position

ABOUT US: Community health is about more than just vaccines and checkups. It’s about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We’re with you every step of the way, with the care you need for each of life’s chapters. At Neighborhood, we are Better Together. As a private, non-profit 501(C) (3) community health organization, we serve over 500,000 medical, dental, and behavioral health visits from more than 100,000 people annually. We do this in pursuit of our mission to improve the health and happiness of the communities we serve by providing quality care to all, regardless of situation or circumstance. We have been doing this since 1969 and it is our employees that make this mission a reality. Regardless of the role, our team focuses on being compassionate, having integrity, being professional, always collaborating, and consistently going above and beyond. If that sounds like an organization you want to be a part of, we would love to have you. ROLE OVERVIEW and PURPOSE: The Care Coordinator will coordinate care for complex patients with mental illness, substance use disorders, or chronic conditions to navigate and link with community resources that address social determinants of health (SDOH). This role will provide care coordination and connection to services and social supports for ECM patients, including appointment scheduling and referral management. Additionally, this position will require travel to other Neighborhood sites as needed to attend the designated meetings as well as training for staff members. This is a hybrid position; on site expectations are dependent on performance. Proposed schedule shifts: Mondays through Fridays 8:30 AM - 5 PM or 9 AM - 5:30 PM (30-min lunch), or 9 AM - 6 PM (1-hour lunch).

Requirements

High school diploma or equivalent required
Two years of healthcare, behavioral health, or social services industry experience required
Active CA driver’s license and proof of car insurance required
Excellent verbal and written communication skills, including superior composition, typing, and proofreading skills
Ability to interact effectively with clinic personnel, patients, and community-based organizations
Knowledgeable about evidenced based communication such as motivational interviewing, or similar empathy-based communication strategies (emotional intelligence)
Knowledge about and experience with providing sensitivity to patients with mental health conditions and addictive disorders
Ability to resolve problems/conflicts
Ability to navigate computer applications, including Microsoft applications
Ability to sufficiently engage members and providers both on the phone and in person
Ability to successfully manage multiple tasks simultaneously
Excellent planning and organizational ability
Ability to work as part of a team as well as independently
Ability to work with highly confidential information in a professional and ethical manner
Ability to lift/carry 25 lbs/weight
Ability to stand for long periods of time

Nice To Haves

Medical Assistant or Phlebotomy certificate preferred
Bilingual (English/Spanish) preferred

Responsibilities

Provides ongoing monitoring of the Targeted Engagement List (TEL)
Assigns patients to the appropriate ECM team members based on risk category and available clinical data for ECM engagement activities
Works with a caseload of patients identified as being low risk
Conducts periodic telephonic outreach and follow-up to low-risk ECM patients as outlined in the Shared Care Plan
Supports other ECM team members with delegated tasks
Assists in the coordination of appointments and referrals for physical and behavioral health appointments
Collaborates on patient care issues with other ECM team members, participating in weekly systematic case reviews and ad hoc case reviews, and consults with ECM team RN and/or the Behavioral Health care team RN before taking any action that is clinical in nature
Connects ECM patients to other social services and supports they may need
Uses relationship-based strategies to engage patients in care as well as motivational interviewing
Assists with arrangements such as transportation, directions, and completion of durable medical equipment requests
Coordinates with ECM patient in the most easily accessible setting, within IEHP guidelines, such as patient home, provider/regional office, or other settings
Contributes to the success of the organization by participating in quality improvement activities
Documents in ECW for all care coordination and other services or teaching provided in a timely manner, as needed
Prioritizes activities according to intensity, need, and required follow-up
Provides accurate and timely reports to supervisor and site staff, as required