Community Care Coordinator

Kaweah Health•Visalia, CA

1d•$23 - $35•Hybrid

About The Position

Kaweah Health is seeking a Community Care Coordinator to join their Enhanced Care Management (ECM) and Community Supports (CS) programs. This role focuses on improving the outcomes and delivery of care for individuals with serious unmanaged health and/or psychological conditions who may not be benefiting from current health services. The coordinator will connect high-utilizing individuals with community resources, aiming to improve health outcomes, reduce redundant healthcare utilization, and assist with housing transitions for those experiencing homelessness. The position involves acting as a lead case manager, navigating patients through medical, behavioral health, social systems, community resources, and housing transitions. It requires collaboration with patients, families, healthcare teams, and outside organizations to address Social Determinants of Health (SDOH) and overcome barriers to care.

Requirements

Valid California Driver's License.
Must provide DMV report prior to offer being made.
No driving infractions 5 years prior to hire or during time in this job. Infractions include DUI, Suspended or Revoked License, Reckless Driving.
Bachelor's degree in Social Work, Psychology, Behavioral Sciences, Health Education, Public Health or related field, or four years of community outreach experience.
Ability to organize and prioritize work.
Excellent diplomacy and negotiation skills.
Good written and verbal skills.
Must have valid transportation and auto insurance.

Nice To Haves

Bilingual in Spanish strongly preferred.
Preferred working knowledge of social service programs and benefits; laws, rules, and procedures governing eligibility for public assistance programs, basic record keeping practices including client related service documentation, use of electronic office tools; client service engagement and accountability.

Responsibilities

Conducts outreach, client engagement, referral, treatment, education, data collection, and supportive community-based services for assigned client caseload.
Works closely with the Primary Care Provider (PCP) team, Patient and Family Services (PFS), Patient Advocates, Financial Counselors, and admissions/benefits staff to assist in patient transitions of care and follow-up.
Provides insight into client challenges and barriers based on home visits to the client’s care team.
Facilitates client access to community resources, including locating housing, food, clothing, school programs, vocational opportunities or services, providers to teach life skills, and relevant mental health services.
Assists clients in developing natural resources and making contact with social support networks.
Acts as a liaison on behalf of the client and care team; encourages and enables patients to attend scheduled appointments.
Responsible for becoming familiar with services available in targeted communities to connect patients and their families with available services.
Advocates for resources and leverages services to provide a comprehensive, seamless system of healthcare for targeted patients.
Makes home visits to assess needs, follows up on challenges and barriers, and provides training to help patients and their families increase their knowledge of their condition and the skills/resources needed to improve their health.
Connects patients with the clinical team to provide education related to medical conditions, nutritional guidance, and medication administration.
Maintains written documentation, records, files, and statistics according to organizational instructions and job function, ensuring accuracy and currency in the electronic health record (EHR) CERNER MILENNIUM.
Coordinates and monitors services, including comprehensive tracking of client activities in relation to the care plan.
Assists clients in developing goals in areas of need and developing treatment plans and health action plans, which are assessed regularly.
Meets with leadership as needed for review of activities, priority setting, and problem-solving.
Keeps Manager informed of progress on projects and special activities.
Develops working knowledge of all areas of public assistance, case processing, eligibility, management, and community resource contacts.
Assesses and evaluates patient social determinants of health (SDOH) challenges and barriers for meaningful and accountable follow-through on healthcare treatment and services.
Acts to develop client self-care abilities, providing tools and education for self-care and self-management of health condition(s) and SDOH challenges.
In the ambulatory clinic system, works closely with assigned RN Case Manager, PCP, Medical Assistant, pharmacy team, and behavioral health provider to schedule Case Conferences as needed.
Assists in the development and implementation of new employee training (if assigned as Lead).
Supports training on new or revised team processes, functions, and resources, including specific local clinic assignment-related functions (if assigned as Lead).
Responsible for scheduling and overseeing students and interns seeking healthcare setting hours of learning (if assigned as Lead).
Recommends and supports the development of new resources and tools for the team, in cooperation with the manager (if assigned as Lead).
Participates in planning and implementation, resource, and health plan meetings to formulate service plans and provide feedback regarding program needs and growth opportunities (if assigned as Lead).
Oversees the provision of services to populations of focus such as high utilization, homeless, severe mental illness (SMI, low to moderate) and implementation of the care plan (if assigned to ECM/CS).
Offers services where the member lives, seeks care, or finds the most easily accessible setting within applicable guidelines (if assigned to ECM/CS).
Connects members to other social services and supports they may need (if assigned to ECM/CS).
Advocates on behalf of members with healthcare professionals (if assigned to ECM/CS).
Uses motivational interviewing and trauma-informed care practices (if assigned to ECM/CS).
Works with hospital staff on discharge plans (if assigned to ECM/CS).
Engages eligible members for ECM and CS programs (if assigned to ECM/CS).
Accompanies enrolled members to office visits, as needed and according to applicable guidelines (if assigned to ECM/CS).
Monitors treatment adherence (including medication) (if assigned to ECM/CS).
Provides health promotion and self-management training (if assigned to ECM/CS).
Arranges transportation (if assigned to ECM/CS).
Forms and fosters relationships with housing agencies and permanent housing providers, including supportive housing providers (if assigned to ECM/CS).
Partners with housing agencies and providers to offer the member permanent, independent housing options, including supportive housing (if assigned to ECM/CS).
Connects and assists the member to permanent housing when available (if assigned to ECM/CS).
Coordinates with the member in the most easily accessible setting, within applicable guidelines (if assigned to ECM/CS).
Partners with community resources and agencies to conduct outreach to target populations (if assigned to Health Navigator Program).
Participates in community activities and events to conduct outreach to target populations and establish relationships for Medi-Cal enrollment and renewal (if assigned to Health Navigator Program).
Assists target population in collecting documents, submitting applications, and supporting documents for enrollment (if assigned to Health Navigator Program).
Conducts outreach to the target population regarding timely re-enrollment (if assigned to Health Navigator Program).
Completes program documentation and submits timely record keeping according to organizational and department instructions (if assigned to Health Navigator Program).
Identifies candidates for ECM and CS programs by reviewing Member Information Files (MIF), upstream referrals, and patient charts for centralized outreach and enrollment (if assigned to CalAIM Administrative Coordination).
Works closely with Population Health RN Manager, RN Case Managers, Population Health Data Team, and Revenue Integrity to ensure accurate documentation and billing reconciliation (if assigned to CalAIM Administrative Coordination).
Verifies Medi-Cal eligibility for all enrolled ECM, CS, and Outreach patients during the first week of the month (if assigned to CalAIM Administrative Coordination).
Confirms eligibility for new patients prior to initiating authorization (if assigned to CalAIM Administrative Coordination).
Obtains Release of Information (ROI) and ensures proper documentation is completed (if assigned to CalAIM Administrative Coordination).
Facilitates the completion of required documents, including Consent of Authorization (COA) and Notice of Privacy Practices (NOPP) (if assigned to CalAIM Administrative Coordination).
Maintains confidentiality and protects sensitive data at all times (if assigned to CalAIM Administrative Coordination).
Creates encounters and checks in new ECM and CS Patients in the scheduling system, Soarian Financials (if assigned to CalAIM Administrative Coordination).
Maintains accurate records, specifically updating encounters as needed when patients switch providers or insurance (if assigned to CalAIM Administrative Coordination).
Maintains accurate encounters for billing purposes (if assigned to CalAIM Administrative Coordination).
Performs an annual reset of encounters by discontinuing them at the end of September and creating new ones October 1st (if assigned to CalAIM Administrative Coordination).
Manages encounters transitioning between programs such as CS Housing Navigation and transition to CS Sustainability to ensure all accounts and billing encounters are accurate (if assigned to CalAIM Administrative Coordination).
Submits and tracks authorizations for ECM and CS services through health plan provider portals (if assigned to CalAIM Administrative Coordination).
Maintains an accurate record of authorization status and expiration dates to mitigate billing and reimbursement issues (if assigned to CalAIM Administrative Coordination).
Ensures re-authorizations are completed diligently at a minimum every six months or as required by program guidelines (if assigned to CalAIM Administrative Coordination).
Communicates in a timely fashion with RN Case Managers regarding authorization delays or barriers to obtaining authorization for services (if assigned to CalAIM Administrative Coordination).
Conducts a thorough review of audit reports to identify and resolve documentation discrepancies in collaboration with the assigned clinic team (if assigned to CalAIM Administrative Coordination).
Processes referrals for services, including Medically Tailored Meals and other CS and ECM offerings (if assigned to CalAIM Administrative Coordination).
Coordinates referrals with care teams to ensure timely delivery of services (if assigned to CalAIM Administrative Coordination).
Supports with program coordination and data management compliance (if assigned to CalAIM Administrative Coordination).
Updates Standard Operating Procedures (SOPs) under the direction of Population Health RN Manager and RN Case Managers to improve efficiency and workflow (if assigned to CalAIM Administrative Coordination).
Attends assigned team meetings, which may include local clinic team, department team, or others, and participates in discussions.
May attend community networking meetings as assigned and applicable to job functions.
Provides outreach and education in the communities of Tulare County.
Transports patients to and from needed locations using a company vehicle.
Assists primary health clinics in these communities to provide outreach and education to the families they are treating.
Provides education and outreach by visiting patients' homes and neighborhoods.
Advocates for resources and services patients may need.
Works directly with appropriate individuals to determine educational materials and develop culturally and linguistically appropriate educational materials.
Completes various projects and assignments associated with the job in a timely manner.
Participates as a student in at least one continuing education course offered annually and demonstrates application within the work setting.
As applicable, maintains membership in appropriate professional and community organizations.
Demonstrates the knowledge and skills necessary to provide care and services appropriate to the population served on the assigned unit or work area.
Performs other duties as assigned.