Care Coordinator - Enhanced Care Management

Neighborhood Healthcare•Riverside, CA

6d•$25 - $35•Hybrid

About The Position

The Care Coordinator coordinates care for complex patients with mental illness, substance use disorders, or chronic conditions, helping them navigate and connect with community resources that address social determinants of health. The position provides care coordination and links Enhanced Care Management (ECM) patients to services and social supports, including appointment scheduling and referral management. It also involves travel to other Neighborhood sites as needed for designated meetings and staff training. This is a hybrid position, with on-site expectations dependent on performance.

Requirements

High school diploma or equivalent.
Two years of experience in the healthcare, behavioral health, or social services industry.
Active California driver’s license and proof of car insurance.
Excellent verbal and written communication skills, including composition, typing, and proofreading.
Ability to interact effectively with clinic personnel, patients, and community-based organizations.
Knowledge of evidence-based communication approaches such as motivational interviewing or similar empathy-based strategies.
Knowledge of and experience providing sensitivity to patients with mental health conditions and addictive disorders.
Ability to resolve problems and conflicts.
Ability to navigate computer applications, including Microsoft applications.
Ability to engage members and providers effectively by phone and in person.
Ability to manage multiple tasks simultaneously.
Excellent planning and organizational ability.
Ability to work both as part of a team and independently.
Ability to handle highly confidential information professionally and ethically.
Ability to lift or carry 25 pounds and stand for long periods.

Nice To Haves

Medical Assistant or Phlebotomy certificate.
Bilingual in English and Spanish.

Responsibilities

Monitor the Targeted Engagement List (TEL) on an ongoing basis.
Assign patients to appropriate ECM team members based on risk category and available clinical data for ECM engagement activities.
Manage a caseload of patients identified as low risk.
Conduct periodic telephone outreach and follow-up with low-risk ECM patients as outlined in the Shared Care Plan.
Support other ECM team members with delegated tasks.
Assist with coordinating physical and behavioral health appointments and referrals.
Collaborate with ECM team members on patient care issues, participate in weekly systematic and ad hoc case reviews, and consult the ECM team RN and/or Behavioral Health care team RN before taking clinical action.
Connect ECM patients with social services and other needed supports.
Use relationship-based strategies and motivational interviewing to engage patients in care.
Assist with transportation, directions, and completion of durable medical equipment requests.
Coordinate with ECM patients in accessible settings, consistent with IEHP guidelines, including patient homes, provider or regional offices, and other settings.
Participate in quality improvement activities.
Document care coordination, services, and teaching provided in ECW in a timely manner, as needed.
Prioritize activities according to intensity, need, and required follow-up.
Provide accurate and timely reports to the supervisor and site staff as required.
Follow safety procedures, maintain knowledge of safe work practices, use appropriate body mechanics, and follow infection-control procedures.
Protect confidential patient, employee, and volunteer information; comply with corporate integrity and security requirements; and report unethical, fraudulent, or unlawful behavior.