ECM Care Coordinator

“Every person deserves compassion, dignity, and the safety of a place to call home.” Homelessness is the largest social and public health crisis in California. Illumination Health + Home is a growing non-profit organization dedicated towards disrupting the cycle of homelessness by providing targeted, interdisciplinary services in our recuperative care centers, emergency shelters, housing services and children's and family programs. IF currently has 13+ facilities with 22+ micro-communities scattered across Orange County, Los Angeles County and the Inland Empire. Job Description The Care Coordinator is a site-based, client-facing role within Care Management, responsible for identifying, engaging, assessing, enrolling, and advocating for specific populations on a regular basis. This individual serves as the primary point of contact for clients who are intermittently housed with Illumination Health + Home. The Care Coordinator establishes strong relationships with clients to support their engagement in medical care, behavioral health services, and social support systems. This role adopts a holistic, non-clinical approach, emphasizing adherence to evidence-based practices, understanding client and service barriers, and considering social determinants of health. The Care Coordinator facilitates appropriate coordination of services for targeted populations, assisting clients in navigating healthcare systems, promoting preventative care, and collaborating closely with the client’s Care Team. The pay range for this position is $24- $26 an hour The schedule for this position is Monday - Friday, 8:30am to 5:00pm Responsibilities Client needs: Provide comprehensive case management by assessing client needs, developing individualized treatment plans, monitoring progress, supporting clients, making appropriate referrals, and conducting follow-up on weekly goals and action steps. Complete care plans and maintain accurate documentation within Electronic Health Records (EHR) and client databases (e.g., HMIS, Champ, or Health Plan programs, if applicable) using SMART format where appropriate. Collaborate with other departments by attending weekly meetings to evaluate program effectiveness, discuss client progress, and develop strategies to meet clients' needs and enhance treatment plans. Connect clients to resources that support their psychosocial and daily needs, including healthcare, nutritional assistance, hygiene supplies, and referrals to transitional or permanent supportive housing and other relevant service providers, such as primary care physicians, and healthcare teams. Perform crisis intervention as necessary. Establish and maintain confidential case files for all participants and review required statistical reports for program management and evaluation purposes. Maintain communication with external agencies involved in client care. Promote awareness and understanding of monthly health promotion topics and materials. Accompany clients to medical appointments and coordinate transportation as needed. Manage a caseload of up to 30-35 ECM members, unless instructed otherwise by senior management within policy guidelines. Prepare for and participate in individual and group supervision sessions. Submit daily End of Shift (EOS) reports to document performance metrics. Compile and submit monthly tally sheets. Outreach clients when applicable. Documentation: Responsible for accurately recording all client interactions and content updates within Illumination Health + Home’s Electronic Medical Record (EMR), in accordance with organizational standards and contractual obligations. Responsibilities include: Progressively documenting all aspects of the client’s care plan, including achieved goals and upcoming objectives Recording engagement levels, such as the frequency and duration of client encounters · Documenting evaluative client case details that inform decisions regarding referrals to alternative resources Recording obtained client documentation, including vitals, insurance cards, SSI award letters, and other relevant records Noting client disengagement and reintegration activities Maintaining awareness of services offered by other providers in the network Upholding strict confidentiality in compliance with agency policies Managing client information, scheduling, files, and documentation materials Tracking attendance at medical appointments and patient navigation sessions, and initiating outreach or follow-up procedures for missed appointments as necessary Mission Support: Uphold and exemplify Illumination Health + Home’s mission and core values through respectful and harmonious interactions with colleagues and management. Demonstrate the ability to quickly learn new skills and procedures, approaching changes with a positive and adaptable attitude. Contribute positively to the organization by being a dependable team member and showing respect to clients and all workplace stakeholders. Act with integrity, transparency, accountability, respect, and responsibility in all professional activities. Consistently display enthusiasm and dedication in representing Illumination Health + Home. Maintain openness, honesty, and accountability in interactions with colleagues, volunteers, donors, and others associated with the organization. Always protect the confidentiality of sensitive work-related information and materials. Take personal responsibility and ownership for the performance of assigned duties. Provide support to volunteers as needed, including supervision responsibilities when applicable. Expectations: Knowledge and application of HIPAA regulations Proficient understanding and utilization of Illumination Health + Home’s Electronic Medical Records system Professional and discreet communication with all current and prospective clients Adherence to Illumination Health + Home’s safety policies and procedures Comprehensive knowledge of and ability to utilize peripheral services necessary to effectively address client needs Continued sensitivity to and awareness of cultural and linguistic diversity Honesty, transparency, and professionalism in all client interactions and engagement efforts Familiarity with Illumination Foundation’s models of care, including harm reduction and social determinants of health Proactive efforts to connect unhoused clients with available resources Experience working with individuals involved with legal or justice systems Collaboration with other onsite and offsite departments Preferred Experience/Minimum Qualifications Required: Bachelor’s degree in Social Services, Healthcare, or a related field; or equivalent combination of training and experience. Experience in homeless services, case management, and mental health support Possessing a valid California driver's license required to operate the company's vehicle to travel to multiple locations on occasions with clients. Must be familiar with VI-SPDAT if applicable Knowledge of resources available in corresponding counties Preferred: Bilingual in English and Spanish Proficiency in Microsoft Office Suite (Outlook, Word, Excel, Calendar, etc.) At least 1 year experience working with at risk/unhoused individuals Experience in non-profit housing and/or housing for people with disabilities and chronic health conditions. Benefits Medical Insurance funded up to 91% by Illumination Health + Home (Kaiser and Blue Shield), depending on the plan Dental and Vision Insurance Life, AD&D and LTD Insurance funded 100% by Health + Home Employee Assistance Program Professional Development Reimbursement 401K with Company Matching 10 days vacation PTO/year 6 days sick PTO/year 10 days holiday PTO/year Potential eligibility for the Public Service Loan Forgiveness Program (PSFL) for federally qualified loans