SC I, Care Coord Comm Supports & Pasadena

Step Up•Los Angeles, CA

21d•Hybrid

About The Position

The Service Coordinator I (SCI) will provide support to both CalAim CS and Pasadena COC ICMS enrolled members. CalAim Community Supports (CS) is a program supporting unhoused and recently housed individuals funded through California Advancing and Innovating Medi-Cal (CalAIM). It coordinates care by utilizing a person-centered approach to maximizing an individual's health and life trajectory. The program will offer Housing Transition Navigation Services, Housing Deposits, and Housing Tenancy and Sustaining Services. Step Up will begin outreach and engagement to promote the services, enroll the members in the CalAIM - CS program, and provide supportive services intended to improve their current housing situation as well as improve their social and physical determinants of health. Members remain in the CS program until they no longer need or want the services. CS services consist of a care team providing in-person supportive services that aim to identify and manage comprehensive needs through improving health outcomes, providing housing support, and addressing social drivers of health. The Pasadena COC ICMS program is designed to provide long-term supportive services and housing stabilization to the Pasadena Housing Division voucher holders. SCIs working with this population will provide case management and linkage, housing navigation, supportive services, and housing retention services to participating voucher holders enrolled in this program. Step Up fully implements the Housing First and Harm Reduction models of service delivery and using the "WHATEVER IT TAKES" approach.

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.
Must have strong organizational skills, computer data entry and other administrative program expertise.
Must be able to conduct basic health data and submit health outcomes such as labs, discharge plans and other health related records.
Must be a mandated reporter.
Must be able to complete and become proficient in Welligent and Clarity/HMIS.
Must ensure the privacy and security of the PHI as outlined in Step Up's policies and procedures relating to HIPAA compliance including attending annual compliance training.
Must be able to conduct tenant screenings and housing assessments.
Must be able to develop an individualized housing support plan.
Must be able to assist in securing housing, including the completion of housing applications and securing required documentation.
Must be able to assist with benefit advocacy.
Must be able to identify and secure available resources to assist with subsidizing rent.
Must be able to identify and secure resources to cover expenses such as security deposits, moving costs, adaptive aids, environmental modifications, and other one-time expenses.
Must be able to assist members in navigating the healthcare system.
Must be able to assist with members' transition upon discharge from medical or psychiatric hospitals.
Must be able to play a key role in crisis response teams.
Must be able to deliver information about health and wellness.
Must be able to assist with the coordination of medical and behavioral health access issues.
Must participate in all formal and informal training courses.
Must model the highest ethical behavior.
Must build and maintain a positive working relationship with members and providers.
Must participate in staff meetings, trainings, individual supervisions, and other activities as needed or directed by Step Up's Housing Services team.
Must 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).
Must complete Care Plans: Due upon enrollment, and updated Care Plans are due every 90 days.
Must verify and document members' income.
Must complete Transition of Care Discharge (TOC): Due within 7 days of the member's admission and discharge from an inpatient hospital stay.
Must submit billable notes to provider portals (Clarity/HMIS), Step Up electronic health records (Welligent) and maintain member's charts and profiles.
Must keep an accurate and up to date calendar to reflect daily schedule.
Must maintain caseload and census daily.
Must report emergencies, urgent care needs, crisis, etc. to Step Up management necessary documentation.

Nice To Haves

Bilingual (English Spanish preferred).

Responsibilities

Provide high quality, effective care management to members enrolled in the CS and Pasadena COC ICMS programs.
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.
Collaborate 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 and 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.
Submit required documents, visit notes, care plans, demographics, legal documents and other mandatory files into provider portals and Step Up program systems on time and on a daily basis.
Conduct basic health data and submit health outcomes such as labs, discharge plans and other health related records.
Act as a mandated reporter and advocate for the health, protection and safety of the enrolled member.
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 including attending annual compliance training.
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, 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 relationship building.
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.
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.
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.