Care Coordinator - Justice-Involved - ECM

VIACARE COMMUNITY HEALTH CENTER•Eastmont, CA

1d•$23 - $28

About The Position

The Justice-Involved (JI) Care Coordinator works with individuals who are transitioning from incarceration. Justice-involved individuals—those who are currently, or have previously been, in jails, youth correctional facilities, or prisons—face a higher risk of injury and death compared to the general population. A care coordinator is a healthcare professional responsible for supporting patients and their families as they navigate each level of care. Care coordinators act as liaisons between patients, providers, community clinics, case managers, and hospitals. They assist patients in connecting with the appropriate programs or facilities for their needs, advocate on their behalf, and ensure all parties have the necessary patient information. Care coordinators are responsible for outreach and engagement efforts, both in person and via phone. They also navigate individual members’ program eligibility, including insurance and specifically Medi-Cal eligibility. All staff within these programs are also expected to support other team members in coordination with the program manager or director.

Requirements

Excellent verbal and written communication skills.
Flexible and able to take initiative
Excellent organization, follow through, and ability to juggle multiple priorities in a fast- paced environment with multiple collaborators
Demonstrated excellent attendance and reliability
Able to work flexible job hours (including some evenings and weekends)
Willingness to work in various environments, including prison/jail settings, street outreach, home visits at SRO, patient’s residence or homeless encampment if applicable to role
Requires high mobility level to provide outreach at various locations
Manual dexterity to operate office equipment, including keyboard, copier, telephone
Must be able to view and work on a computer for a long period of time, ability to use Microsoft office and internet

Nice To Haves

History of prior incarceration or lived experience
Recent experience (last 3 years) working as part of a multi-disciplinary team, collaboratively practicing with PCPs, health workers, health educators, and other health professionals.
Bilingual English/Spanish
Valid California driver’s license and excellent driving record

Responsibilities

Function as a supportive member of an interdisciplinary healthcare team, using an integrated care and treatment approach.
Provide education, outreach, case management, and navigational services to qualifying members with the most complex medical and social needs
Collaborate with individual case managers to connect ECM members with primary care providers (PCP) and related providers as needed to navigate toward health and behavioral interventions that will improve patient health outcomes.
Responsible for expanding case managers' caseloads by contacting potential members.
Manage extensive internal and external program referrals, including in-clinic providers, managed care plan referrals, and case manager outreach.
Reporting member compliance to all managed care plans and consistently meeting reporting deadlines each month.
Monitor and update online spreadsheets that assist in tracking referrals and documenting patient information
Verify outdated data and update patient files as needed.
Ability to interpret various types of information and convert physical documents to digital platforms.
Ability to develop relationships with Managed Care Plans (MCPs) and their liaisons. You will need to attend monthly meetings and training sessions.
Stay informed about programmatic updates and new populations added to ECM.
Participates regularly in Via Care program meetings.
Prepare and disseminate program material, find and recruit participants, assess individual and community needs, promote health literacy, and be an advocate
Community/cultural liaison to Via Care’s Intensive Care Management Services
Assists patients through the healthcare system by operating as a patient advocate and health systems navigator.
Coordinates continuity of patient care with external healthcare organizations and facilities.
Coordinates continuity of patient care with patients and families/caregivers following hospital admission, discharge, and Emergency Department visits.
Facilitate clients in their comprehensive health self-screenings to collect functional, environmental, psycho-social, employment, housing, educational, and health information, as appropriate as it relates to health outcomes
Engage families, conduct assessments, suggest referrals, give feedback to case managers, and produce documentation
Educates patients about the health care system and facilitates relationship-building between the two
Documents work with patients through appropriate record-keeping that follows the project’s policies and procedures
Participates/assists as needed in any activities related to the clinic and in collaboration with partners of the clinic
Attends ongoing training for community health workers/case managers & care coordinators
Advises patients and others regarding health care and other facilities available to them; assists patients in utilizing services; makes follow-up contacts when required
Assist in gathering and evaluating data concerning the program to which assigned; may perform incidental clerical duties such as keeping records, answering the telephone, and arranging client appointments
Other duties as assigned:
These duties may be modified, and the functions of the job description may be based on the needs of the organization.