SC I, Care Coord Comm Supports & Pasadena

Step Up • Los Angeles, CA

22d • $25 - $28 • Hybrid

About The Position

The Service Coordinator I (SCI) role supports two programs: CalAim Community Supports (CS) and Pasadena COC ICMS. The CalAim CS program, funded by California Advancing and Innovating Medi-Cal (CalAIM), focuses on unhoused and recently housed individuals, using a person-centered approach to improve health and life trajectories through services like Housing Transition Navigation, Housing Deposits, and Housing Tenancy and Sustaining Services. The Pasadena COC ICMS program offers long-term supportive services and housing stabilization for Housing Division voucher holders, providing case management, housing navigation, supportive services, and housing retention. Both programs operate under the Housing First and Harm Reduction models, with an "WHATEVER IT TAKES" approach. The SCI will provide field-based services, including outreach, engagement, care coordination, resource linkage, and support for members' health goals, while also addressing mental health behaviors and coordinating care such as appointment scheduling and referral management.

Requirements

• AA degree or equivalent.
• 2 years' experience working in community outreach, homelessness, and/or a behavioral health or substance use disorder program.
• A valid California driver's license and clean driving record.
• A reliable vehicle and valid automobile insurance is mandatory, as automobile travel is required in LA County either by personal or company vehicle.
• A clean report Department of Justice background check.
• Highly skilled interpersonally, with excellent relationship skills.
• Knowledgeable and skilled in Evidenced based communication such as Motivational Interviewing or similar empathy-based communication strategies.
• Able to sufficiently engage with members and healthcare providers in a variety of settings such as on the phone, at member's homes, streets if homeless, in hospitals and other health settings.
• Ability to develop relationships with community members and leaders, including in the faith-based community.
• A high degree of skillful decision-making and judgement, in an autonomous position, including knowing when to consult with the team, supervisors, and experts.
• Understanding of and sensitivity to mental health conditions and addictive disorders.
• Understanding of and sensitivity to multi-cultural communities.
• Awareness of the impact of unmitigated bias, and judgement on health; a commitment to addressing both.
• Understanding of, and a commitment to, high performing team practices.
• Keyboard data entry required.

Nice To Haves

• Bilingual (English Spanish preferred).

Responsibilities

• Provide support to both CalAim CS and Pasadena COC ICMS enrolled members.
• Provide field-based services including outreach and engagement, housing tenancy and sustaining services, housing transition and navigation services, coordination of care, and resource linkages.
• Engage members focusing on their present health goals, concerns, and needs.
• Work with other professionals and organizations in the community to ensure quality of care for members.
• Address present mental health behaviors and coordinate member's care such as appointment scheduling and referral management, resource linkages, transportation, and/or durable medical equipment requests.
• Collaborate care with the member's primary care physician (PCP) and ensure both members and PCP participate in the development of care plan.
• Strategize with an interdisciplinary team and management.
• Work collaboratively with enrolled members' families, and other professionals including the designated care team, health professionals and organizations in the community to ensure quality of care for members, seamless transition of care, and facilitation of services.
• Use relationship-based strategies to engage members in care as well as motivational interviewing or similar empathy-based strategies.
• Complete and become proficient in Welligent and Clarity/HMIS to ensure documentation is accurate and in compliance with regulatory requirements and accreditation standards.
• Ensure the privacy and security of the PHI as outlined in Step Up's policies and procedures relating to HIPAA compliance.
• Participate in outreach and engagement efforts to enroll referred members in CS.
• Assist members in navigating the housing market and applying for units.
• Complete Pasadena COC application packets with members.
• Provide advocacy on behalf of members in the home, the community, and in provider organizations.
• May transport and attend any appointments to ensure successful completion of and outcomes of each goal.
• Conduct tenant screenings and housing assessments that identify the member's preferences and barriers related to successful tenancy.
• Develop an individualized housing support plan based upon the housing assessment that addresses identified barriers, includes short and long-term measurable goals for each issue, and establishes the member's approach to meeting the goal.
• Search for housing and present options to the members.
• Assist in securing housing, including the completion of housing applications and securing required documentation.
• Assist with benefit advocacy, including assistance with obtaining necessary documentation to apply for Social Security and supporting the Social Security/SSI application process.
• Identify and secure available resources to assist with subsidizing rent.
• Identify and secure resources to cover expenses such as security deposits, moving costs, adaptive aids, environmental modifications, and other one-time expenses.
• Assist members in navigating the healthcare system, helping members successfully participate in their medical and/or behavioral health care by overcoming barriers to care, sharing information on barriers with the PCP to improve care and outcomes.
• Assist with members' transition upon discharge from medical or psychiatric hospitals by coordinating with hospital discharge planning and being supportive in plan transitions.
• Collaborate within the hospital to connect with members before they are released to start the relationship building that is important for the care coordinator's success in member engagement.
• Navigate housing, routinely revisit the care plan, and support members in attending follow-up appointments.
• Play a key role in crisis response teams that provide community-based alternatives to justice involvement.
• Deliver information about health and wellness in ways that the community can easily understand and provide information on MCP benefits and services.
• Transport and attend appointments to ensure successful completion of and outcomes of each health-related goal or task.
• Engage with members in a manner that utilizes evidence-based approaches, such as motivational interviewing, that promotes collaboration between the member and their health.
• Assist with the coordination of medical and behavioral health access issues with Step Up programs, PCP offices, and specialists.
• Participate in all formal and informal training courses to gain continued knowledge on medical conditions including treatments and evidence-based for treatment always staying within scope.
• Model the highest ethical behavior in relationship with co-workers, supervisor, members, provider, and colleagues in the community and within Step Up.
• Build and maintain a positive working relationship with members and providers including by not limited to communication via in-person, over the phone, and through digital means, such as email and fax.
• Participate in staff meetings, trainings, individual supervisions, and other activities as needed or directed by Step Up's Housing Services team.
• Any other duties as required to ensure CS and Pas COC ICMS operations are successful.
• Document every client contact within 48 hours using case notes GIRP format (Goal, Intervention, Response, Plan) and other documents utilizing in prescribed record system (CLARITY/HMIS, Welligent, and/or hard copy files).
• Complete Care Plans: Due upon enrollment, and updated Care Plans are due every 90 days.
• Verify and document members' income.
• Complete Transition of Care Discharge (TOC): Due within 7 days of the member's admission and discharge from an inpatient hospital stay.
• Submit billable notes to provider portals (Clarity/HMIS), Step Up electronic health records (Welligent) and maintain member's charts and profiles.
• Keep an accurate and up to date calendar to reflect daily schedule.
• Maintain caseload and census daily.
• Report emergencies, urgent care needs, crisis, etc. to Step Up management necessary documentation.

Benefits

• Opportunities for growth and professional development.
• Generous paid time off (13 paid holidays, 10 days of EPTO, 12 sick days).
• Competitive salary and benefits package.
• Health, dental, vision, Aflac, and life insurance $25,000.00
• 403(b) retirement plan available on the first day of work.
• Step Up matches 3% of the 6% the employee contributes to the 403(b) retirement plan after working 1000 hours.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree