ECM Care Coordinator: Patient-Centered Care Navigator

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

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