Care Coordinator - ECM Program

Duties And Responsibilities The Care Coordinator (CC) engages potential ECM program members and assists with linkage to case management support. A CC is a health care professional whose duties and responsibilities are to support patients and their families as they move through each level of care. Care Coordinators function as liaisons between patients, providers, the community clinic and hospital. You help the patient connect with the appropriate program or facility for their level of care, advocate on their behalf, and ensure all parties have the appropriate patient information. CCs are responsible for the outreach and engagement program both in-person and telephonic. CCs are also charged with the navigation of individual members’ program eligibility involving insurance and specifically Medi-Cal eligibility. CCs will also be assigned to support other team members in coordination with the program manager/director. Essential Functions The functions performed by employees in this job family will vary by level or the area(s) to which assigned but may include (and not be limited to) the following. Employee must perform all duties and responsibilities in accordance with Via Care’s care standards. Operate as a supportive role within an interdisciplinary healthcare team utilizing an integrated care and treatment model. Provide education, outreach, case management, and navigational services to qualifying members with the most complex medical and social needs. Collaborate with individual case managers to connect ECM members toward primary care providers (PCP) and related providers as needed to navigate toward health and behavioral interventions that will maximize patient health outcomes. Responsible for increasing case manager caseloads by outreaching potential members. Handle large amounts of internal and external program referrals not limited to in-clinic providers, managed care plan referrals, and case manager outreach. Reporting member compliance to all managed care plans and meeting reporting deadlines on a monthly basis. Monitor and update online spreadsheets that assist in tracking referrals and documenting patient information. Verify outdated data and make necessary changes to patient files. Ability to understand various forms of information and transfer hard copy to digital platforms. Ability to establish relationships with Managed Care Plans (MCPs) and corresponding liaisons. You will be required to participate in monthly meetings and training courses. Stay up to date with programmatic changes and new populations of focus added to ECM. Participates regularly in Via Care Program Meetings Outreach And Community Mobility Prepare and disseminate program material, find, and recruit participants, assess individual and community needs, promote health literacy, and be an advocate. Community/cultural liaison to Via Care’s Intensive Care Management Services. Assists patients through the healthcare system by operating as a patient advocate and health systems navigator. Coordinates continuity of patient care with external healthcare organizations and facilities. Coordinates continuity of patient care with patients and families/caregivers following hospital admission, discharge, and Emergency Department visits. Facilitate clients in their comprehensive health self-screenings to collect functional, environmental, psycho-social, employment, housing, educational, and health information, as appropriate as it relates to health outcomes. Engage families, conduct assessments, suggest referrals, give feedback to case managers, and produce documentation. Educates patients about the health care system and facilitates relationship-building between the two. Documents work with patients through appropriate record-keeping that follows the project’s policies and procedures. Participates/assists as needed in any activities related to the clinic and in collaboration with partners of the clinic. Attends ongoing training for community health workers/case managers & care coordinators. Advises patients and others regarding health care and other facilities available to them; assists patients in utilizing services; makes follow-up contacts when required. Assist in gathering and evaluating data concerning the program to which assigned; may perform incidental clerical duties such as keeping records, answering the telephone, and arranging client appointments. Other duties as assigned. These duties may be modified, and functions of the job description based on the needs of the organization. Knowledge, Skills, And Abilities Excellent verbal and written communication skills. Flexible and able to take initiative. Excellent organization, follow through, and ability to juggle multiple priorities in a fast- paced environment with multiple collaborators. Demonstrated excellent attendance and reliability. Manual dexterity to operate office equipment, including keyboard, copier, telephone. Must be able to view and work on a computer for a long period of time, ability to use Microsoft office and internet. #J-18808-Ljbffr Via Care Community Health Center