ECM Care Coordinator

Northern Valley Indian Health; Woodland (CA); On-site; USD 52,000 - 69,000; Full time

Benefits offered by this job

Health insurance

Paid time off

Supplemental benefits

Job summary

Northern Valley Indian Health in Woodland, CA seeks a dedicated Care Coordinator to manage a caseload of patients requiring comprehensive care solutions. You will collaborate with clinical and operational teams, conduct patient intake for ECM, connect patients with resources, and support families through care planning and follow-up.

The role requires a Bachelor's in Social Work or related field, 1 year of healthcare case management experience, strong communication, and proficiency with EHR

Qualifications

• Bachelor’s degree in Social Work, Psychology, Sociology or related field.
• Minimum of one year of healthcare case management experience; 2 years preferred.
• Proficient in reading, interpreting, and supporting complex care plans.
• Knowledge of clinical medical, behavioral health and substance use disorder terminology.
• Advanced computer skills with experience using EHR systems.
• Ability to travel for training; California driver’s license and reliable transportation.

Responsibilities

• Manage individual caseload by conducting comprehensive assessments of patient’s medical, behavioral, and social needs when referred for Enhanced Care Management services.
• Develop individualized care plans, implement services, conduct follow-up, and monitor patient needs and care plans.
• Use motivational interviewing and other techniques to support behavior change and adherence to care plan.
• Coordinate with primary care providers, specialists, behavioral health professionals, and community organizations to support patient-centered care.
• Educate patients and families about managing health conditions and navigating the healthcare system.
• Facilitate referrals, navigations, case management services, and linkages to community resources.
• Conduct or coordinate outreach activities in diverse community settings to expand program reach.
• Maintain accurate documentation of assessments, care plans, interactions, and outcomes per requirements.
• Build relationships with agencies and providers to advocate for patients and increase program visibility.
• Assist the team in addressing escalation concerns from patients and staff.

Skills

Care coordination

Communication

Teamwork

Cultural sensitivity

Critical thinking

Self-motivation

Travel readiness

Public speaking

Education

Bachelor’s degree in Social Work, Psychology, Sociology or related field

Tools

EHR systems

Job description

At Northern Valley Indian Health, our message has always been clear. YourHealth Is Our Mission.

At NVIH we have a culture based around prioritizing the health andwell-being of not just our patients and community members but ouremployees as well. From comprehensive insurance coverage, extensive paidtime off, and numerous supplemental benefits, NVIH has consistentlyshown employees how we value their personal and professional well-being.We are a growing organization but will always remain firm in ourcommitment to employee health and well-being.

• Salary : $25.00 USD per hour - $33.00 USD per hour

Job Description

POSITION SUMMARY: Under the general supervision of the Supervising Care Coordinator, the Care Coordinator (CC) works collaboratively with other departments at NVIH to manage a caseload of patients requiring comprehensive and/or complex care solutions, with the ultimate goal of improving health outcomes. The CC provides care management services through various tools and methods, including conducting a patient intake for the Enhanced Care Management (ECM) program, connecting patients with necessary resources, building strong relationships with patients and their families, and following up based on patient needs. Strong collaboration with clinical care teams and operational teams is essential to ensure a holistic approach to patient support. This position requires effective communication, organizational skills, and the ability to work in a team-oriented environment to fulfill the role's responsibilities successfully.

ESSENTIAL JOB FUNCTIONS: The list that follows is not intended as a comprehensive list, but rather to provide a representative summary of the major duties and responsibilities. Incumbent(s) will be required to perform a variety of duties listed, including but not limited to:

1. Manage individual caseload by conducting comprehensive assessments of patient’s medical, behavioral, and social needs when referred for Enhanced Care Management services.

2. Participate in developing individualized care plans, implementing the services, conducting follow-up, and monitoring the patient’s needs and care plan.

3. Use motivational interviewing and other techniques to support behavior change and adherence to care plan.

4. Coordinate with primary care providers, specialists, behavioral health professionals, and community-based organizations to support a patient-centered approach to care.

5. Provide education and support to patients and their families about managing their health conditions and navigating the healthcare system, while empowering patients to take an active role in their care.

6. Facilitate referrals, navigations, case management services, and linkages to community resources to address patient needs and follow up to ensure services are received and effective.

7. Conduct or coordinate outreach activities in diverse community settings, fostering connections and expanding program reach.

8. Maintain accurate and timely documentation of patients’ assessments, care plans, interactions and outcomes in accordance with regulatory and program requirements.

9. Build and maintain strong working relationships with agencies, organizations, and healthcare providers to advocate for patients and increase program visibility.

10. Assist the team in addressing and resolving escalation concerns from both patients and staff related to the program.

11. Other duties as assigned.

All NVIH employees are expected to:

- Provide the highest possible level of service to patients;

- Promote teamwork and cooperative effort among employees;

- Maintain safe practices; and

- Abide by current NVIH’s policies and procedures.

Experience and Skills

REQUIRED QUALIFICATIONS:The following knowledge, skills, and abilities are required for an employee to successfully perform their duties.

• Bachelor’s degree in Social Work, Psychology, Sociology or related field required.
• Minimum of one (1) year of experience in a healthcare case management or care coordinator role required; 2 years preferred.
• Proficient in reading, interpreting, and supporting complex care plans through critical thinking and sound judgement.
• Knowledge of clinical medical, behavioral Health and substance use disorder terminology is required.
• Demonstrated ability to grow and enhance personal and professional skills, as evidenced by achieving subject matter expert status in previous roles.
• Strong cross-departmental collaboration and teamwork skills to facilitate patient care coordination activities.
• Effective written and verbal communication skills, with the ability to speak publicly.
• Proven ability to engage with underserved communities in a culturally sensitive manner.
• Ability to effectively work independently with minimal supervision; self-driven to plan workload and accomplish objectives.
• Able to travel for training; must maintain a valid California driver’s license, meet agency auto insurance requirements, and have reliable transportation.
• Advanced computer skills with experience using Electronic Health Records (EHR) systems.

Native Preference. Northern Valley Indian Health provides Native Preference in hiring practices for qualified Native applicants, in accordance with its policy. NVIH is also an Equal Opportunity and At Will Employer

Northern Valley Indian Health is required to collect and maintain summary information on the gender, ethnic background, and veteran status of applicants. Providing the requested information is VOLUNTARY and will have no bearing on your consideration for employment at NVIH. This information is confidential and will be used for statistical purposes only.

Northern Valley Indian Health (NVIH), under the Indian Preference Act (Title 25, U.S. Code Sections 472 & 473), provides preference in filling vacancies to Native American applicants. In other than the preceding, NVIH provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national original, age, disability, or status as a Vietnam-era or special disabled veteran in accordance with applicable federal laws. In addition, NVIH prohibits discrimination on the basis of creed, sexual orientation, gender identity, marital status, or presence of a physical, mental, or sensory disability, in accordance with applicable state and local laws. 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.