Service Coordinator I Care Coordinator ECM

Step Up•San Bernardino, CA

4h•Hybrid

About The Position

The Community Health Worker (CHW) supports individuals enrolled in the Enhanced Care Management (ECM) program who have complex medical, behavioral health, and social needs. The CHW serves as a trusted liaison between participants, healthcare providers, social service agencies, and community resources. Working in collaboration with ECM clinical staff, the CHW conducts outreach, engagement, care coordination, health education, and resource navigation to help participants access services and improve health outcomes. The CHW plays a key role in addressing social drivers of health, reducing barriers to care, and promoting participant self-management and stability.

Requirements

High school diploma or equivalent required.
Community Health Worker Certification required.
Minimum 1–2 years experience working with vulnerable or high-need populations.
Possesses ability to work both independently and as a member of a multi-disciplinary team.
Strong interpersonal and relationship-building skills.
Cultural humility and trauma-informed approach.
Motivational interviewing techniques.
Knowledge of community resources and social services.
Ability to work independently in community settings.
Strong organizational and documentation skills.
Basic computer skills and experience with electronic health records.
Effective communication and advocacy skills.
Must be able to travel locally for outreach and participant support.

Nice To Haves

Homeless or housing-insecure populations
Individuals with substance use disorders
Serious mental illness
Justice-involved individuals
High utilizers of emergency services

Responsibilities

Conduct outreach to eligible or enrolled ECM participants in community settings, homes, shelters, clinics, homeless encampments, or hospitals throughout the Inland Empire.
Build trusting relationships with participants through culturally responsive and trauma-informed engagement.
Assist with onboarding and orientation to ECM services.
Maintain consistent contact with participants through phone, in-person visits, and community-based engagement.
Work closely with ECM Case Managers, Nurses, and Behavioral Health providers to implement participant care plans.
Support coordination between primary care, behavioral health, specialty care, and social service providers.
Assist participants with scheduling medical, behavioral health, and social service appointments.
Accompany participants to appointments when appropriate to support engagement and communication.
Assist participants in accessing services related to housing stability, food access, transportation, public benefits, employment resources, legal services, and education or vocational programs.
Provide referrals and warm handoffs to community-based organizations and support services.
Provide education on chronic disease management, medication adherence, and preventive care.
Reinforce health goals identified in the participant care plan.
Support participants in understanding medical instructions and navigating healthcare systems.
Document all outreach, contacts, and services provided in the program’s electronic health record (EHR) or care management system.
Maintain accurate and timely records in accordance with ECM documentation requirements.
Participate in case conferences and multidisciplinary care team meetings.
Track participant progress and report barriers to care.
Maintain knowledge of local community resources and service providers.
Develop relationships with community-based organizations to facilitate participant access to services.
Participate in community outreach and engagement activities.