Outreach Care Coordinator

Los Angeles Christian Health Centers; Los Angeles (CA); Presencial; USD 60.000 - 90.000; Jornada completa

Descripción de la vacante

Los Angeles Christian Health Centers seeks an Outreach Care Coordinator in Los Angeles to lead Medi-Cal ECM care management, linking patients to medical, behavioral health, housing and benefits resources while promoting the center's mission. Responsibilities include community outreach, referral management, care coordination, and SMART goal setting with patients.

CPR is required; two years of case management; BA in social work or related field preferred; bilingual Spanish is a plus; experience

Formación

• Two years of case management experience is required.
• Bachelor's degree in social work or related field preferred.
• Experience with homelessness, substance use, physical health and mental health conditions is desirable.
• Bilingual Spanish preferred.

Responsabilidades

• Assess, organize, and initiate partnership activities to enhance services for current and potential patients.
• Represent the organization at community and faith-based events.
• Attend community meetings and coalitions.
• Build and maintain relationships with community partners.
• Conduct street outreach weekly.
• Use effective communication to engage vulnerable clients.
• Link clients to care and community resources.
• Assist with scheduling appointments and paperwork for patient care.
• Supply or obtain items like hygiene kits and clothing.
• Coordinate Care Coordination outreach and enrollment for ECM.
• Provide care coordination and transition planning.
• Create SMART goals with patients.

Conocimientos

Bilingual Spanish

English proficiency

Educación

Bachelor's degree in social work or related field

Herramientas

Electronic Health Records (EHR)

HMIS

CHAMP

Microsoft Word

Microsoft Excel

Descripción del empleo

Summary

The Outreach Care Coordinator will support and promote LACHC's mission to follow Christ by loving and serving our neighbors through comprehensive, quality healthcare. The OCC will serve as a Lead Care Manager for the Medi-Cal Enhanced Care Management (ECM) program. As Lead Care Manager, the OCC is responsible for maintaining all biopsychosocial care management services for enrolled patients, including strategies to address medical, behavioral, social, and long-term services and supports needs. In addition to individual care coordination, the OCC engages in initiatives designed to promote the organization and its services to the community and promote new patient outreach and enrollment.

Community Outreach

Essential Duties and Responsibilities Include:

• Assess, organize, and initiate partnership activities to enhance services provided to current and potential patients.
• Represent the organization at community and faith-based events and activities.
• Attend community meetings, such as coalition and advocacy meetings, community updates, case conferencing, etc.
• Build and maintain positive working relationships with community partners.
• Conduct street outreach on a weekly basis.
• Use effective communication skills such as active and reflective listening to build rapport with vulnerable and difficult-to-engage clients.
• Use evidenced based outreach strategies to locate clients and link them to care.
• Motivate patients to be active and engaged participants in their health.
• Assist patients with scheduling appointments and assisting with completion of registration paperwork for patient care.
• Supply or obtain necessary items, such as hygiene kits, clothing, blankets, etc.
• Assess supply needs for patient population and strategize resolution.
• Organize, promote, and track in-kind donation initiatives for Care Coordination.
• Utilize, maintain, and update LACHC resource guide as changes occur and keep resource information on-hand to give to clients for all applicable resources.
• Conduct outreach and enrollment calls to eligible patients for ECM.
• Ability to work in groups as well as self-guided, independent outreach and coordination.
• Demonstrable experience and understanding of coalition building and nonprofit advocacy, engagement with relevant initiatives, and briefings to departmental leadership.

Care Coordination

Engage in Care Coordination Activities as Indicated, Which May Include:

• Monitor and encourage treatment plan adherence.
• Manage referrals, coordination, and follow‑up for services and supports.
• Ensure appropriate care at level of care transitions by providing evidence‑based transition planning.
• Assisting clients with linkage and access to vital and appropriate resources per eligibility status, such as:
• Housing.
• Substance abuse treatment.
• Mental health care.
• Public benefits.
• Assist with documentation and identification needs.
• Assist clients with locating and obtaining transportation to/from appropriate medical and/or social service appointments.
• Expertise in administering structured assessments, including assessments on Social Determinants of Health, to gather, track, and assess client progress.
• Provide immediate assistance to patients as needed, including locating emergency shelter, food resources, etc.
• Apply Harm Reduction strategies to engage with clients, including participation and certification in Narcan training.
• Provide accompaniment services to clients as needed, determined by patient assessment and interviews.
• Utilize strengths‑based, solution‑focused strategies to assist patients.
• Create SMART goals in collaboration with patients.
• Other Duties as Assigned.

Qualifications

• CPR Certification required.
• Bi‑lingual Spanish preferred.

Education And/or Experience

• Two years of case management experience is required.
• Bachelor's degree in social work or related field from a four‑year college or university is preferred.
• Prior experience working with individuals experiencing homeless, substance use, physical health conditions, mental health conditions.

Computer Knowledge

• Experience with Electronic Health Records, Microsoft Word, Microsoft Access, and Microsoft Excel is preferred.
• Experience with HMIS and CHAMP databases preferred.

Language Skills

• Familiarity with medical terms and operations of clinics is useful.
• Proficiency in English required, Bi‑lingual/ Bi‑literal Spanish is preferred.

Mathematical Skills

• Ability to calculate figures and amounts such as totals, proportions and percentages.

Reasoning Ability

• Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
• Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
• Ability to independently make decisions in high‑pressure situations.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit and talk or hear. The employee frequently is required to use hands to finger, handle, or feel. The employee is occasionally required to stand; walk; reach with hands and arms; climb or balance; and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee will be exposed to carriers of contagious diseases. The employee may have to deal with irate and irrational clients who may or may not be under the influence of mind‑altering substances such as cocaine, marijuana, alcohol, etc.

Work Status

Regular, Full‑time, Non‑exempt position. Medical, Dental and Vision with 403B Retirement Plan with employer match. Equal Opportunity Employer. Willing to consider candidates with criminal history.