Care Coordinator

ASIAN PACIFIC HEALTH CARE VENTURE•Los Angeles, CA

4d•$23 - $27•Hybrid

About The Position

The Care Coordinator performs essential functions of care management and care coordination as part of the Care Team for the Enhanced Care Management Program. The Care Coordinator manages specified cases, coordinates health care benefits, provides education and facilitates member access to care in a timely and cost-effective manner. The Care Coordinator collaborates and communicates with member, family/support persons, providers, and the Enhanced Care Management Team to promote wellness and member empowerment, while ensuring access to appropriate services and maximizing member benefit. The Care Coordinator serves as a clinical advocate for members, active interdisciplinary team member, liaison with other departments and external health and social service providers. The Care Coordinator is also responsible for providing short-term service plan for the referred client/patients as related to utilization/ follow-up of external community resources. The Care Coordinator shall also assist in other care coordination programs as assigned by Director of Performance Improvement, including administration of (1) APHCV’s Remote Patient Monitoring Program, where he/she will monitor and track distribution of RPM equipment, provide and/or facilitate patient education on the use and care of the RPM equipment, and provide overall implementation coordination of the RPM program; (2) Care coordination of AWV visits for Medicare beneficiary including outreach and appointment scheduling and (3) Care coordination of tobacco cessation services and linkages of care for cessation services. APHCV expects all employees to respond and participate to emergency situation per emergency policies and procedures. APHCV requires all staff to comply with Standards of Conduct and Compliance Program related policies and procedures. Such compliance is part of this position’s performance evaluation.

Requirements

Associate’s or Bachelor’s degree
Comfortable working with diverse populations.
Exceptional ability to connect and engage with people.
Ability to engage members
Critical thinking skills & effective verbal and written communications skills to consult with members, physicians, and providers
Ability to use a personal computer and document care management activities.
Obtain a certificate of completion as defined and accepted by APHCV that adequately certifies one’s demonstrated skills to perform CHW duties. Such certification may include certificate issued by the State of California or a State designee, of a curriculum that attests to demonstrated skills and/or practical training; or Have at least 2,000 hours in a paid or volunteer position within the last 3 years and have demonstrated the skills described within the state link as approved by APHCV.
A CHW who does not have a certificate of completion must earn a certificate within 18 months of the first CHW visit provided to a Medi-Cal beneficiary
Complete a minimum of 6 hours of continuing education training annually after the initial certification.
Legal authorization to work in the United States
Completion of APHCV Health Assessment Form
Completion of DOJ background check
Ability to lift up to 25 lbs.

Nice To Haves

Additional years of qualifying work experience may be considered in lieu of degree
Previous experience providing case management and/or care coordination for vulnerable and/or underserved populations
Motivational interviewing
Current knowledge of clinical standards of care and disease processes.
Knowledge of community resources in area of residence.
Familiarity with trauma-informed care and harm reduction practices
Bilingual in one of LA County’s Medi-Cal threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese.

Responsibilities

Serve as a Care Coordinator function for ECM enrolled members.
Conduct Comprehensive Health Assessment to assess member needs in the areas of physical health, mental health, SUD, community-based Long Term Services & Supports, oral health, palliative care, trauma-informed care, social supports, and housing (as appropriate for individuals experiencing homelessness).
Oversee provision of Health Action Plan services and implementation of Health Action Plan
Connect ECM member to other social services and supports he/she may need
Advocate on behalf of members with health care professionals
Use motivational interviewing, trauma-informed care, and harm-reduction practices
Work with hospital staff on discharge plan
Conduct outreach to and engage eligible ECM members to encourage enrollment in the program
Monitor treatment adherence (including medication)
Provide health promotion and self-management training
Arrange transportation
Document and submit for claims all ECM related encounters for services rendered.
Administer Remote Patient Monitoring program for APHCV’s Chronic Care Management Program.
Monitor, track and report on distribution of RPM equipment
Provide and/or facilitate patient education on the use and care of the RPM equipment.
Attend and participate in HRSA NHCI program activities.
Conduct outreach and schedule AWV appointments for APHCV Medicare beneficiaries, both managed care and non managed care.
Coordinate referrals for Chronic Care Management services of Medicare beneficiaries.
Coordinate linkages of cessation services for smokers through ensuring cessation referrals are completed
Participate in State Tobacco Cessation program as Care Coordinator and community liaison.
Work with other staff to develop, maintain cessation workflow completion.
Navigation services for patients to be able to utilize available resources and health and human services system.
Health promotion, education and information.
Assistance to have patients receive the services they need
Provide patient social support for building individual capacity to help him/herself
Follow up with patients so that they complete care, linking to APHCV’s service, in-house and external specialists, and outside services.
Provide screening and assessment to patients.
Individual support or advocacy that assists patient in preventing the onset or exacerbation of a health condition or preventing injury or violence.
Participate in various QI and QA activities as assigned.
Any other duties CEO and/or DPI might assign.