ECM Care Coordinator

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: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and update online spreadsheets that assist in tracking referrals and documenting patient information.Verify outdated data and make necessary changes to patient files.Ability to understand various forms of information and transfer hard copy to digital platforms.Ability to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 MeetingsOutreach 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.Recent experience (last 3 years) working as part of a multi-disciplinary team, collaboratively practicing with PCPs, health workers, health educators, and other health professionals.Bilingual English/SpanishSPECIAL REQUIREMENTSAble to work flexible job hours (including some evenings and weekends)Willingness to work in various environments, including various Via Care clinics or external social service provider offices as applicable.Requires high mobility to connect with patients at various locations.Excellent driving record and automobile insurance coverage.Subject to a criminal background check prior to employment.TB clearance, to be renewed every year. Vaccines and boosters as needed.Compliance with all mandated vaccinations and all boosters is a term and condition of employment.Equal Opportunity StatementVia Care Community Health Center provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, marital status, amnesty, or status as a covered veteran in accordance with applicable federal, state and local laws. Via Care Community Health Center complies with applicable state and local laws governing non-discrimination in employment in every location in which the organization has facilities. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.In compliance with California Labor Code § 432.3, as amended effective January 1, 2026, this job posting includes the pay scale for the position. The pay scale represents a good‑faith estimate of the salary or hourly wage range the employer reasonably expects to pay for the position upon hire. Actual compensation within the posted range will depend on experience, skills, and internal equity. #J-18808-Ljbffr