Community Care Coordinator

Kaweah Health•Visalia, CA

2d•$23 - $35

About The Position

Improves the outcomes and delivery of care to those individuals who have serious unmanaged health and/or psychological conditions and uses health services in ways that do not result in positive health outcomes. Connects high utilizing individuals with available resources in the community to improve their health outcomes, reduce redundant health care utilization, and procure housing in the case of homelessness. The Community Care Coordinator coordinates the provision of patient care within programs such as Enhanced Care Management (ECM), and Community Supports (CS) to ensure patients’ care is continuous and integrated amongst service providers. Acts as the lead case manager for patients and will be responsible for the navigation of patient’s medical health, behavioral health, social systems, community resources and housing transitions. Involves patients and their family members, the health-care team members and outside organizations to reduce and address Social Determinants of Health (SDOH) and 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 the admissions/benefits staff to assist in patient transitions of care and follow up.
Provides insight into the 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 client to develop natural resources and make contact with social support networks.
Acts as liaison on behalf of the client and care team; will encourage and enable when necessary patients to go to scheduled appointments.
Responsible for becoming familiar with the services available in the targeted communities in an effort to connect patients and their families with available services.
Advocates for resources and leveraging services to provide a comprehensive, seamless system of health care for targeted patients.
Makes home visits to assess needs, follows up on challenges and barriers, provides training to help patients and their families to increase their knowledge of the disease/condition, and the skills and resources necessary to increase their abilities to become more healthy as individuals.
Connects patient with clinical team to provide education relative to medical conditions, nutritional guidance and medication administration.
Maintains written documentation, records, files, and statistics according to organizational instructions and job function.
Ensures records and files are completed accurately, kept current and maintained in the electronic health record (EHR) CERNER MILENNIUM.
Coordinates and monitors services, including comprehensive tracking of client activities in relation to care plan.
Assists clients in developing goals in areas of need and assists in 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, community resource contacts.
Assesses and evaluates patient social determinants of health (SDOH) challenges and barriers for meaningful and accountable follow through on health care 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 self-management of social determinants of health 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 Conference as needed.
Assists in development and implementation of new employee training.
Supports training new or revised team processes, functions, resources, including specific local clinic assignment related functions.
Responsible for scheduling and overseeing students and interns seeking health care setting hours of learning.
Recommends and supports development of new resources and tools for the team, in cooperation with the manager.
Participates in planning and implementation, resource, health plan meetings to formulate service plans and give feedback regarding program needs and growth opportunities.
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.
Offers services where the member lives, seeks care, or finds the most easily accessible setting within applicable guidelines.
Connects members to other social services and supports he/she may need.
Advocates on behalf of members with health care professionals.
Uses motivational interviewing and trauma informed care practices.
Works with hospital staff on discharge plans.
Engages eligible members for ECM and CS programs.
Accompanies enrolled members to office visits, as needed and according to applicable guidelines.
Monitors treatment adherence (including medication).
Provides health promotion and self-management training.
Arranges transportation.
Forms and fosters relationships with housing agencies and permanent housing providers, including supportive housing providers.
Partners with housing agencies and providers to offer the member permanent, independent housing options, including supportive housing.
Connects and assists the member to permanent housing when available.
Coordinates with the member in the most easily accessible setting, within applicable guidelines.
Partners with community resources and agencies to conduct outreach to target populations.
Participates in community activities and events to conduct outreach to target populations and establish relationships with target populations for purposes of Medi-Cal enrollment and renewal.
Assists target population in collecting documents, submitting application and supporting documents for enrollment.
Conducts outreach to the target population regarding timely re-enrollment.
Completes program documentation and submit timely record keeping according to organizational and department instructions.
Identifies candidates for ECM and CS programs by reviewing Member Information Files (MIF), upstream referrals and patient charts to conduct centralized outreach and enrollment.
Works closely with Population Health RN Manager, RN Case Managers, Population Health Data Team, Revenue Integrity to ensure accurate documentation and billing reconciliation.
Verifies Medi-Cal eligibility for all enrolled ECM, CS and Outreach patients during the first week of the month.
Confirms eligibility for new patients prior to initiating authorization.
Obtains Release of Information (ROI) and ensures proper documentation are completed.
Facilitates the completion of required documents, including Consent of Authorization (COA) and Notice of Privacy Practices (NOPP).
Maintains confidentiality and protects sensitive data at all times.
Creates encounters and checks in new ECM and CS Patients in the scheduling system, Soarian Financials.
Maintains accurate records specifically updating encounters as needed when patients switch providers or insurance.
Maintains accurate encounters for billing purposes.
Performs an annual reset of encounters by discontinuing them at the end of September and creating new ones October 1st.
Manages encounters transitioning between programs such as CS Housing Navigation and transition to CS Sustainability to ensure all accounts and billing encounters are accurate.
Submits and tracks authorizations for ECM and CS services through health plan provider portals.
Maintains accurate record of authorization status and expiration dates to mitigate billing and reimbursement issues.
Ensures re-authorizations are completed diligently at minimum every six months or as required by program guidelines.
Communicates in a timely fashion with RN Case Managers regarding authorization delays or barriers to obtaining authorization for services.
Conducts thorough review of audit reports to identify and resolve documentation discrepancies in collaboration with assigned clinic team.
Processes referrals for services, including Medically Tailored Meals and other CS and ECM offerings.
Coordinates referrals with care teams to ensure timely delivery of services.
Supports with program coordination and data management compliance.
Updates Standard Operating Procedures (SOPs) under the direction of Population Health RN Manager and RN Case Managers to improve efficiency and workflow.
Attends assigned team meetings, which may include local clinic team, department team or other, and participates in discussion.
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 the primary health clinics in these communities to provide outreach and education to the families they are treating in those areas.
In addition, provides education and outreach by visiting patients' homes and neighborhoods.
Advocates for resources and services the patients may need.
Works directly with appropriate individuals to determine the educational materials in an effort to develop educational materials that are culturally and linguistically appropriate.
Completes various projects and assignments associated with 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.