SOCIAL SERVICES CARE COORDINATOR for ECM

RAVENSWOOD FAMILY HEALTH CENTER•East Palo Alto, CA

21d•$30 - $35•Onsite

About The Position

The Social Services Care Coordinator for Enhanced Care Management (ECM) provides case management services for California Advancing and Innovating Medi-Cal (CalAIM). Under the administrative direction of the Senior Manager of Social Services, Manager of Social Services, and Integrated Behavioral Health and Social Services Director, this role helps develop collaborative treatment and care management plans that support patients’ physical and mental health, substance use disorder, community-based long-term services and supports, social supports, and social determinants of health. The coordinator conducts comprehensive assessments, care coordination, outreach and engagement, identifies patient support needs, makes referrals to community social supports, and fosters patient autonomy and independent skills. The position works closely with the Senior Manager of Social Services. Ravenswood Family Health Network’s mission is to improve community health through culturally sensitive, integrated primary and preventative care for all, regardless of ability to pay or immigration status, while collaborating with community partners to address social determinants of health. This role is based at 1885 Bay Road in East Palo Alto, California, and requires travel to clinic locations, patients’ residences, and other community settings. The position is full-time, pays $30.00–$35.00 per hour, and may require flexible hours, including evenings and occasional weekends.

Requirements

High school diploma or GED certificate.
Excellent interpersonal, oral, and written communication skills.
Strong organizational, problem-solving, and analytical skills, with the ability to manage competing priorities and workflow.
Proactive approach to daily tasks, flexibility, and good judgment.
Proficiency in data entry and computer software.
California driver’s license with a clean record.
Personal registered automobile with current insurance, in good operating condition.
Ability to travel to all clinic locations, patients’ residences, and other community settings.
Basic Life Support (BLS) certificate.

Nice To Haves

Associate degree and/or bachelor’s degree.
One year of experience working in a healthcare or social service setting providing mental health outreach services.
Experience with EPIC software.
Bilingual proficiency in Spanish.
Up-to-date COVID-19 vaccines according to current CDC guidelines are strongly recommended.

Responsibilities

Serve as the primary contact for enrolled ECM members and advocate for them as they navigate the healthcare system.
Conduct outreach and engagement in diverse community settings, including street-level outreach, and complete ECM enrollment documents with members at home, in clinic, or in the community.
Maintain compliance with applicable county, state, and federal laws and regulations, funder requirements, and program requirements, including timely and accurate documentation in EPIC and health plan electronic systems.
Manage an active caseload of approximately 30–40 cases, depending on patient acuity.
Complete patient outreach within the timeframe specified by the member’s health plan after receiving a referral.
Monitor care plan implementation and update plans as needed.
Develop care management plans addressing physical health, mental health, substance use disorder, community-based long-term services and supports, oral health, palliative care, social supports, and social determinants of health.
Support patient engagement in treatment by scheduling appointments, sending reminders, coordinating transportation, accompanying patients to critical appointments, and addressing other barriers to treatment.
Maintain regular contact with patients and their family members, guardians, caregivers, and/or authorized support persons as part of care coordination.
Help patients participate in and manage their care, and educate members on self-management skills using harm-reduction approaches and motivational interviewing.
Encourage patients to strengthen their skills in identifying and accessing resources to manage and prevent chronic conditions.
Provide transitional care during hospital discharge and coordinate adherence support, referrals, and community resources as needed.
Help patients access benefits such as SSI, CalFresh, and cash aid, and obtain required application documentation.
Maintain current documentation needed to collect data and statistics about program outcomes, demographics, and funder requirements.
Consult with medical and mental health providers and participate in case conferences to assess patients’ mental and physical status and health.
Establish program policies, procedures, and standard work guidelines.
Attend meetings, report program activity status during one-to-one meetings with the supervisor and other requested meetings, and promptly escalate urgent or critical issues to the supervisor.
Perform other related duties as assigned by the supervisor.