Community Care Coordinator - Tehama

Ministerial Association of Colusa C; Red Bluff (CA); On-site; USD 60,000 - 90,000; Full time

Job summary

The Community Care Coordinator role at the Ministerial Association of Colusa County (MACC) focuses on coordinating Enhanced Care Management (ECM) and Community Supports, ensuring plan goals align with members’ health and psychosocial needs.

Under CalAIM program guidelines, you will engage eligible members, coordinate services, arrange transportation, and document care activities. Strong communication and regulatory knowledge are essential for collaboration with providers and staff.

Qualifications

• Strong documentation skills and ability to maintain records.
• Ability to multi-task and prioritize when needed.
• Ability to independently seek out resources and work collaboratively.
• Ability to develop and maintain good working relationships with staff.
• Ability to use computer and learn new software programs.
• Excellent interpersonal skills for effective communication with all levels.
• Ability to navigate regulatory oversight by state and federal entities.
• Ability to communicate effectively in writing and verbally.

Responsibilities

• Engages eligible members and offers services where they live, within health plan guidelines.
• Oversee provision and implementation of Care and/or Housing Plans for ECM/CS services.
• Connect with ECM members via phone or in-person for engagement, assessment, and follow-up.
• Collaborate with members to identify Plan goals and objectives.
• Link members to other Community Supports and social services as needed.
• Accompany members to office visits as required by MACC/MCP guidelines.
• Arrange transportation and convene care conference meetings; coordinate with partners for Plan updates.
• Enter data into Case Documentation and reporting systems.
• Attend required trainings and train staff on updates.
• Work with Program Director to ensure ECM templates capture needed data.
• Review MACC protocols and policies and develop new workflows.
• Assist with ECM reports and internal reports.
• Coordinate with individuals/entities to ensure seamless experiences and avoid duplication of services.

Skills

Documentation

Multitasking

Collaboration

Communication

Computer skills

Interpersonal skills

Regulatory knowledge

Travel ability

Education

Medical Assistant, CNA, or Behavioral Health or Social Services paraprofessional with 2+ years case management

AA in social work, sociology, human services or related fields

Combination of education, certifications, and experience in related fields

Tools

MS Outlook

MS Word

MS Excel

Job description

Description

PneumaCare Health and Wellness is dedicated to serving the most vulnerable members of our community by fostering stability and resilience in the areas of Community Supports, Enhanced Care Management and Day Habilitation. We are supported by the mission of the Ministerial Association of Colusa County (MACC), our mother organization, by partnering with the local church to empower our communities through the Gospel.

Under the direct supervision of the CalAIM Program Manager, the Community Care Coordinator is responsible for coordinating and implementing Enhanced Care Management (ECM) and Community Supports Management. Overseeing and implementing provision of the Enhanced Care Management and CS services; and identification and achievement of Plan goals and objectives with the member that meet their self-identified strengths and health care and psychosocial needs.

Job Description

• Engages eligible members, offers services where the member lives, seeks care, or finds most easily accessible and within health plan guidelines.
• Oversee provision of services and implementation of the Care and/or Housing Plans.
• Connects with ECM member via phone or in-person to facilitate engagement, assessment, follow-up, and education/training visits in order to develop and address the Care and/or Housing Plans.
• Works in conjunction with member to identify Plan goals and objectives.
• Connects member to other Community Supports, social services and supports he/she may need.
• Accompanies member to office visits, as needed and according to health plan guidelines.
• Arranges transportation and responsible to convene care conference meetings, while Coordinating with resource partners to obtain data/information to ensure accurate Plan updates.
• Utilize Case Documentation systems and other electronic tracking systems to coordinate services and input data for reporting.
• Attends required trainings. Facilitates internal trainings/updates to clinical and administrative staff members.
• Collaborates with Program Director to ensure ECM templates are appropriate and effective at capturing needed data/information.
• Reviews existing MACC protocols and polices to match requirements. Develops new protocols, policies, and accompanying workflows.
• Assists the required ECM reports and other internal reports.
• Responsible for coordinating with those individuals and/or entities to ensure a seamless experience for the Member and non-duplication of services

• Advocate on behalf of Members with health care professionals
• Uses motivational interviewing, trauma- informed care, and harm-reduction approaches
• Coordinate with hospital staff on discharge plan
• Accompany Member to office visits, as needed and according to MACC and MCP guidelines
• Monitor treatment adherence (including medication)
• Provide health promotion and self- management training
• Other duties as assigned.

Knowledge, Skills, and Abilities

• Strong documentation skills.
• Ability to multi-task and prioritize when needed.
• Ability to independently seek out resources and work collaboratively.
• Ability to develop and maintain good working relationships with staff.
• Ability to use computer and learn new software programs.
• Excellent interpersonal skills reflecting clarity, diplomacy, and the ability to communicate accurately and effectively with all levels of staff and management.
• Demonstrates ability to work in a regulatory climate that includes oversight of state and federal entities, payer contracts etc.
• Possesses ability to communicate effectively, both verbally and in writing.
• Proficient knowledge of Microsoft Outlook, MS Word and Excel.
• Able to travel and attend professional meetings, conferences, trainings, and clinic sites.

Physical and Environmental Requirements

• Ability to remain in a stationary position and work on a computer at a desk for extended periods. Be able to use a computer, keyboard, mouse, and interact with a monitor.
• Ability to complete physical and digital paperwork.
• Ability to walk across variable terrain to reach clients camped outside.
• Ability to travel locally to client homes, service providers, and community resources (valid driver’s license and reliable transportation may be required).
• Ability to regularly lift and/or move up to 20 pounds.
• Work is performed in office, community, and field settings.
• Must agree with and sign MACC's Statement of Common Understanding

Qualifications

There are three different ways that successful candidates may qualify for this role. Candidates can qualify with any one of them.

1. Medical Assistant, CNA, or Behavioral Health or Social Services paraprofessional with at least 2 years of case management or related experience in the field.
2. AA in social work, sociology, human services or related fields preferred, 3-5 years of experience providing home health and/or social services case management services to low-income populations with one or more of the following: complex chronic conditions, high utilizer of emergency room and tertiary health care services, severe mental illness, and/or homelessness.
3. Possess a combination of skills and experience relevant to the role, including but not limited to case management, social services, healthcare, mental health support, and homelessness intervention. Candidates may demonstrate their qualifications through a combination of education, certifications, and practical experience in related fields.

NOTE: Candidates with less educational experience will be considered if lived experience is indicated

Optional Qualifications

• Bilingual in English/Spanish preferred (oral and written)