ECM Care Coordinator

VIACARE COMMUNITY HEALTH CENTER•Los Angeles, CA

3d•$24 - $29•Onsite

About The Position

The Care Coordinator (CC) engages potential Enhanced Care Management (ECM) program members and assists with linkage to case management support. The CC supports patients and families as they move through levels of care, serving as a liaison among patients, providers, the community clinic, and hospitals. The role helps patients connect with appropriate programs or facilities, advocates on their behalf, and ensures relevant patient information is available to involved parties. The CC conducts outreach and engagement in person and by telephone, navigates members’ program and insurance eligibility, including Medi-Cal eligibility, and supports other team members in coordination with the program manager or director. Working as part of an interdisciplinary team, the CC provides education, outreach, case management, and navigation to members with complex medical and social needs. The role coordinates with case managers, primary care providers, managed care plans, external healthcare organizations, patients, and families to promote continuity of care and access to health and behavioral health services. The CC also tracks referrals and patient information, reports member compliance to managed care plans, participates in meetings and training, and stays current on program changes and populations served. The position includes community outreach and mobility, participant recruitment, health literacy promotion, advocacy, assessments, referrals, documentation, and follow-up. Work may take place at Via Care clinics or external social service provider offices. The role requires flexible hours, including some evenings and weekends, and travel to connect with patients at various locations. Employment is subject to a criminal background check, annual TB clearance, and compliance with required vaccinations and boosters.

Requirements

Recent experience within the last three years working as part of a multidisciplinary team and collaboratively with primary care providers, health workers, health educators, and other health professionals.
Bilingual English and Spanish.
Excellent verbal and written communication skills.
Flexibility and ability to take initiative.
Excellent organization, follow-through, and ability to manage multiple priorities in a fast-paced environment with multiple collaborators.
Demonstrated excellent attendance and reliability.
Manual dexterity to operate office equipment, including a keyboard, copier, and telephone.
Ability to view and work on a computer for extended periods and use Microsoft Office and the internet.
Ability to work flexible hours, including some evenings and weekends.
Willingness to work in various environments, including Via Care clinics and external social service provider offices.
High mobility to connect with patients at various locations.
Excellent driving record and automobile insurance coverage.
Subject to a criminal background check prior to employment.
TB clearance, renewed annually.
Compliance with mandated vaccinations and boosters; vaccines and boosters as needed.

Responsibilities

Engage potential ECM members and link them to case management support through in-person and telephone outreach.
Support patients and families as they move through levels of care, acting as a liaison among patients, providers, clinics, hospitals, and community organizations.
Connect ECM members with primary care providers and other services, including health and behavioral health interventions.
Increase case manager caseloads by outreaching potential members and handle internal and external program referrals.
Navigate members’ program eligibility, insurance, and Medi-Cal eligibility.
Report member compliance to managed care plans and meet monthly reporting deadlines.
Monitor and update online spreadsheets used to track referrals and document patient information; verify and update patient files and transfer information from hard copy to digital platforms.
Establish relationships with managed care plans and their liaisons, and participate in monthly meetings and training courses.
Stay current with program changes and new ECM populations of focus; participate in Via Care program meetings.
Prepare and disseminate program materials, recruit participants, assess individual and community needs, promote health literacy, and advocate for participants.
Serve as a community and cultural liaison to Via Care’s Intensive Care Management Services and help patients navigate the healthcare system.
Coordinate continuity of care with external healthcare organizations and facilities, and with patients and families or caregivers after hospital admission, discharge, and emergency department visits.
Facilitate comprehensive health self-screenings and gather functional, environmental, psychosocial, employment, housing, educational, and health information as appropriate.
Engage families, conduct assessments, suggest referrals, provide feedback to case managers, and document activities.
Educate patients about the healthcare system, support relationship-building with it, and advise patients about available healthcare and other facilities and services.
Maintain records in accordance with project policies and procedures and make follow-up contacts when required.
Assist with program data gathering and evaluation and perform incidental clerical duties, including recordkeeping, answering telephones, and arranging appointments.
Participate in clinic activities and collaborate with clinic partners; attend ongoing training for community health workers, case managers, and care coordinators.
Perform other duties as assigned; duties and functions may be modified based on organizational needs.