Care Coordinator

Family HealthCare Network•Visalia, CA

6d•$22 - $30

About The Position

The Care Coordinator is responsible for coordinating patient care within the Health Home Program (HHP) to ensure continuous and integrated care among service providers. This role also supports the Care Coordinator Manager in implementing the HHP. Key responsibilities include navigating patients through health, behavioral health, and social systems, as well as supporting housing transitions. Collaboration with patients, families, healthcare teams, and external organizations is essential to reduce or eliminate barriers to care.

Requirements

Proficiency in written and verbal communication, basic mathematics, computer applications, and technical systems.
Completion of an Bachelor’s Degree program with a recognized major and a minimum cumulative GPA of 2.5 is preferred; OR a combination of relevant experience and proof of completion of high school with a minimum overall GPA of 2.5 or completion of General Educational Development (GED) with a minimum overall score of 162.5.
If an individual has completed a degree at a higher level than required by the role and had a stronger GPA in that program, they may provide proof of GPA from that degree in lieu of the high school diploma.
Two years of experience, knowledge, and training in the field of social work, nursing, health sciences, health education, or a related field; OR be a paraprofessional with more than 7 years of directly related progressive work experience.
Ability to prepare more complex documents in Microsoft Word, including creating tables, charts, graphs and other elements.
Ability to use Microsoft Excel to review and compile data, including the use of formulas, functions, lookup tables and other standard spreadsheet elements.
Ability to create basic presentations in Microsoft PowerPoint.
Ability to compile information prepared in effective written form, including correspondence, reports, articles or other documentation.
Effectively conveys technical information to non-technical audiences.
Regularly required to sit and use repetitive hand movement to type and grasp.
Frequently required to stand and walk.
Must occasionally lift and/or move up to 20 pounds.

Nice To Haves

Completion of an Bachelor’s Degree program with a recognized major and a minimum cumulative GPA of 2.5 is preferred.

Responsibilities

Support patient-centered, continuous, and consistent care, ensuring assigned Health Home Program (HHP) patients receive access to needed services identified through the assessment process.
Coordinate, maintain, and service panels of patients with special service needs, as determined by the Health Home Program and stratification process.
Work with the patient to implement their Health Action Plan (HAP).
Assist the patient in navigating health, behavioral health, and social services systems, including housing and transportation.
Share options with the patient for accessing care and provide information regarding care planning.
Identify barriers to the patient’s treatment.
Monitor and support treatment adherence, including medication management.
Assist in the attainment of the patient’s goals as described in the HAP.
Encourage patient decision-making and continued participation in HHP.
Accompany patients to appointments as needed.
Monitor referrals, coordination, and follow-ups to ensure needed services and supports are offered and accessed.
Share information with all involved parties to monitor the patient’s conditions, health status, care planning, medications usage, and side effects.
Create and promote linkages to other services and supports.
Facilitate communication and understanding between HHP patients and healthcare providers.
Provide health promotion services, such as providing training materials and teaching self-management skills pertaining to the patient’s goals identified in the Health Action Plan (HAP) as part of the HHP.
Encourage and support health education for the patient and family/support persons.
Assess the patient’s and family/support persons’ understanding of the patient’s health condition and motivation to engage in self-management.
Coach patients and family/support persons about chronic conditions and ways to manage health conditions based on the member’s preferences.
Link the patient to resources for smoking cessation, management of chronic conditions, self-help recovery resources, and other services based on patient needs and preferences.
Use evidence-based practices, such as motivational interviewing, to engage and help the patient participate in and manage their care.
Utilize trauma-informed care practices.
Provide Individual, Family, and Community Support Services.
Assess the strengths and needs of the patient and family/support persons.
Link the patient and family/support persons to peer supports and/or community-based groups to educate, motivate, and improve self-management.
Connect the patient to self-care programs to help increase their understanding of their conditions and care plan.
Promote engagement of the patient and family/support persons in self-management and decision-making.
Determine when patient and family/support persons are ready to receive and act upon information provided and assist them with making informed choices.
Advocate for the patient and family/support persons to identify and obtain needed resources (e.g., transportation) that support their ability to meet their health goals.
Accompany the patient to clinical appointments, when necessary.
Identify barriers to improving the patient’s adherence to treatment and medication management.
Act as a housing navigator, assisting patients with housing transition services and individual housing and tenancy sustaining services.
Conduct a tenant screening and housing assessment plan.
Develop a housing support plan which includes prevention and interventions when housing is jeopardized.
Coach on the roles, rights, and responsibilities of the tenant and landlord, lease compliance, and household management.
Foster relationships with housing agencies to explore independent housing options and assist patients with available temporary and permanent housing.
Follow safety plan department work instructions to ensure the safety of staff and patients in the community during outreach activities.
Complete Annual Health and Safety training yearly.
Provide comprehensive transitional care.
Bring to the attention of a Clinical Consultant (e.g., nurse or medical provider) any issues regarding medication information and reconciliation.
Plan timely scheduling of follow-up appointments with recommended outpatient providers and/or community partners.
Collaborate, communicate, and coordinate with all involved parties.
Ease the patient’s transition by addressing their understanding of rehabilitation activities, self-management activities, and medication management.
Plan appropriate care and/or place to stay post-discharge, including temporary housing or stable housing and social services.
Arrange transportation for transitional care, including to medical appointments.
Develop and facilitate the patient’s transition plan.
Consult with Clinical Consultant (e.g., nurse) regarding prevention and tracking of avoidable admissions and readmissions which could trigger a re-evaluation of the HAP.
Provide transition support to permanent housing.
Support the Care Coordinator Supervisor in the implementation of Health Home Program initiatives, curriculum, and objectives.
Support Care Coordinator Supervisor in the collection of data and reporting.
Complete necessary reporting and documentation associated with HHP per organizational and regulatory requirements.
Interface with patients and other stakeholders through a variety of mechanisms, including individual, face-to-face contacts, telephone and other electronically mediated contacts, and contact outside of FHCN Health Centers to provide linkages to appropriate community resources.
Reduce barriers to care when interacting with health-care team members by preparing and distributing information for Pre-visit Huddles, maintaining regular communication on patient care plan goals and progress, and facilitating regular communication between patient and other health-care team members.
Provide staff training and education sessions necessary to implement health education services.
Participate in meetings and trainings as necessary to facilitate duties, including those geared toward implementing evaluation tools.
Adhere to the Attendance and Absenteeism Policy.
Present to and work at any FHCN location based on business need.
Perform other duties as assigned.