Care Coordinator

Family Healthcare Network • Porterville, CA

93d • $21 - $30

About The Position

The Care Coordinator coordinates the provision of patient care within the Health Home Program (HHP) to ensure the patients' care is continuous and integrated amongst service providers, as well as supports the Care Coordinator Manager in the implementation of the HHP. There will be responsibility for the navigation of the patient's health, behavioral health, social systems, community resources, and housing transitions. There will be collaboration with patients and their family members, health-care team members, and outside organizations to reduce or eliminate barriers to care.

Requirements

• Job duties require knowledge and training in the field of social work, nursing, health sciences, health education or a related field.
• A Bachelor's degree with at least one year of experience is preferred.
• Ability to prepare complex documents in Microsoft Word.
• Ability to use Microsoft Excel to review and compile data.
• Ability to create basic presentations in Microsoft PowerPoint.

Responsibilities

• Support patient centered, continuous and consistent care, ensuring that an assigned Home Health Program (HHP) patient receives access to needed services identified through the assessment process.
• Coordinating, maintaining and servicing panels of patients with special service needs.
• Working with the patient to implement their Health Action Plan (HAP).
• Assisting the patient in navigating health, behavioral health, and social services systems.
• Sharing options with the patient for accessing care and providing information regarding care planning.
• Identifying barriers to the patient's treatment.
• Monitoring and supporting treatment adherence (including medication management).
• Encouraging the patient's decision making and continued participation in HHP.
• Accompanying patients to appointments as needed.
• Monitoring referrals, coordination, and follow ups to ensure needed services and supports are offered and accessed.
• Creating and promoting linkages to other services and supports.
• Helping facilitate communication and understanding between HHP patients and healthcare providers.
• Providing health promotion services similar to the role of a health educator.
• Assessing the patient's and family/support persons' understanding of the patient's health condition.
• Coaching patients and family/support persons about chronic conditions.
• Linking the patient to resources for smoking cessation and management of chronic conditions.
• Using evidence‐based practices, such as motivational interviewing, to engage and help the patient participate in and manage their care.
• Providing Individual, Family and Community Support Services.
• Conducting a tenant screening and housing assessment plan.
• Developing a housing support plan which includes prevention and interventions when housing is jeopardized.
• Fostering relationships with housing agencies to explore independent housing options.
• Completing Annual Health and Safety training yearly.
• Planning timely scheduling of follow‐up appointments with recommended outpatient providers.
• Collaborating, communicating, and coordinating with all involved parties.
• Easing the patient's transition by addressing their understanding of rehabilitation activities.
• Planning appropriate care and/or place to stay post‐discharge.
• Arranging transportation for transitional care.
• Developing and facilitating the patient's transition plan.
• Consulting with Clinical Consultant regarding prevention and tracking of avoidable admissions.
• Supporting the Care Coordinator Supervisor in the implementation of Health Home Program initiatives.
• Completing necessary reporting and documentation associated with HHP.

Benefits

• Hourly Rate: $21.99 - $30.35

What This Job Offers

• Job Type: Full-time
• Industry: Ambulatory Health Care Services
• Education Level: Bachelor's degree