Care Coordinator - Enhanced Care Management

Neighborhood Healthcare•Temecula, CA

6d•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 role provides care coordination and links Enhanced Care Management (ECM) patients to services and social supports, including appointment scheduling and referral management. The position is hybrid, with onsite expectations dependent on performance, and requires travel to other Neighborhood sites as needed for designated meetings and staff training. The Care Coordinator monitors and supports ECM patients, particularly those identified as low risk, and works with the ECM team to assign patients according to risk category and available clinical data. The role collaborates with clinical and behavioral health staff, connects patients to social services, coordinates appointments and referrals, and documents services in ECW. The position also supports organizational quality improvement and follows applicable safety, infection control, privacy, and compliance procedures.

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 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 by phone and in person.
Ability to manage multiple tasks simultaneously.
Excellent planning and organizational ability.
Ability to work independently and as part of a team.
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 certificate.
Phlebotomy certificate.
Bilingual in English and Spanish.

Responsibilities

Provide ongoing monitoring of the Targeted Engagement List (TEL).
Assign patients to appropriate ECM team members based on risk category and available clinical data for ECM engagement activities.
Work with 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 appointments and referrals for physical and behavioral health appointments.
Collaborate on patient care issues with ECM team members, 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 supports they may need.
Use relationship-based strategies and motivational interviewing to engage patients in care.
Assist with arrangements such as transportation, directions, and durable medical equipment requests.
Coordinate with ECM patients in accessible settings, such as the patient's home, a provider or regional office, or other settings, within IEHP guidelines.
Participate in organizational quality improvement activities.
Document care coordination and other services or 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, report injuries and unsafe conditions, maintain knowledge of safe work practices, use appropriate body mechanics, and follow infection control procedures, including blood-borne pathogen protocols.
Protect patient, employee, and volunteer information and access it only on a need-to-know basis for business purposes.
Comply with corporate integrity and security regulations and report unethical, fraudulent, or unlawful behavior or activity.