The ECM Care Coordinator will lead the assessment, treatment planning and ongoing care management of eligible participants. The Care Coordinator utilizes motivational interviewing to engage participants and support their motivation to better manage their own chronic conditions. The Care Coordinator actively engages other team members to remove barriers to health, social services, and behavioral health care. This is a very flexible position.
2 years of direct care management experience including working independently in the field, conducting biopsychosocial assessments, and developing care plans preferred.
Experience navigating health and social service systems.
Experience linking people with complex health, behavioral health, and social needs to community resources.
Demonstrated ability to support, coach, and motivate participants to reach their goals.
Valid California driver’s license, reliable transportation and proof of current liability insurance required
Ability to work effectively from home daily (private workspace, stable internet connection, etc.).
Ability to manage time effectively in order to complete tasks and meet deadlines
Experience using electronic technology (laptop, tablet, cell phone) and Microsoft Office Suite (Excel, Word) ,Windows 10 and Microsoft Edge.
Participate in Interdisciplinary Care Team (ICT) meetings with Supervisor/Health Plan to ensure the quality and appropriateness of services being provided to the participant, and to better support participant’s ability to access needed health care services and community resources.
Daily documentation of activities in the care coordination database.
Complete all telephone and face to face contacts with participants in a timely and professional manner.
Complete participant-centered care plans with goals, interventions outcomes and identify barriers in collaboration with participants and review progress in meeting goals routinely.
Meet with participants in person (when permitted by DHCS), and be flexible to meet participants in homes, restaurants, physician offices, and in homeless encampments and other places not suitable for habitation.
Identify, assess, and complete Child Protective Services and Adult Protective Services and recognize Suicidal ideation protocols/referrals per state mandated reporter requirements.
Provide regular and timely updates to medical providers, referral sources, and assigned clinics on participants' progress to meet treatment goals and to troubleshoot any problems or concerns.
Complete all required documentation and data tracking in a detailed and timely manner.
Assist with all other duties assigned.
Attend and actively participate in weekly supervision, training and meetings as scheduled to ensure staff’s understanding and ability to apply best practices and evidence-based practices while working with participants.
While performing the duties of this job, the employee is regularly required to identify, communicate, and exchange information.
Expected to travel to community meetings, participant homes or other agencies, predominately remote