Care Coordinator Care Coordinator

Care Coordinator

REPORTS TO: Program Manager

HOURS: 40

CLASSIFICATION: Hourly

SUMMARY: The Enhanced Care Management (ECM) program is a funded through California Advancing and Innovating Medi-Cal (CalAIM), and is a program that coordinates care by utilizing a person-centered approach to maximizing individual’s health and life trajectory. The ECM provides extra care and coordination services to certain EMC patients with complete medical needs and chronic conditions.  All ECM members must be enrolled in a Managed Care program Molina Healthcare, or Health Net. CalAIM will improve Medi-Cal for people with complex needs and who are facing difficult life and health circumstances. It is focused on breaking down the traditional walls of health care – extending beyond hospitals and health care settings into communities. As a key part of CalAIM, Enhanced Care Management (ECM) is a new statewide Medi-Cal benefit available to select “Populations of Focus" that will address clinical and non-clinical needs of the highest-need enrollees through intensive coordination of health and health-related services. It will meet beneficiaries wherever they are – on the street, in a shelter, in their doctor's office, or at home. The program is designed to leverage existing community care management infrastructure and experience.

DUTIES:

The following reflects essential functions for this job but does not restrict other tasks, which may be assigned:

The Care Coordinator is responsible for working effectively with and as part of the Step Up’s ECM interdisciplinary team to provide high quality, effective care management to ECM members. The Care Coordinator will provide field-based services including: outreach and engagement to members, engaging members in skilled therapeutic interactions to promote health behaviors, coordination of care, resource linkages, working with other professionals and organizations in the community to ensure quality of care for members, seamless transition of care, and facilitating the right care and the right time for the members. This position works collaboratively with Step Up’s ECM team members, member families and other professionals including the designed PCP care team.

CARE COORDINATION AND ADMINSTRATIVE SUPPORT:

1. Participate in outreach and engagement efforts to enroll referred members in ECM.

2. Responsible for assisting Members with care coordination needs, including, but not limited to, referral support, community resource connection, arranging transportation and confirming appointments and other health care navigation.

3. May transport and accompany members to any appointments to ensure successful completion of and outcomes of each health-related goal or task.

4. Engage with members both in person and on the phone in a manner that utilizes evidence-based approaches, such as MI, that promote collaboration between the member and his or her health.

5. Provide Program administrative support for all record keeping, monitoring referrals and follow up visits. Ensure members see their PCP with 60 days of enrollment in ECM as a recommended best practice. Provide support for the team in a general capacity.

6. Participate in all formal and informal trainings to gain continue in knowledge on medical conditions including treatments and evidence-based for treatment always staying within scope.

HOUSING NAVIGATION (if assigned):

1. Form and foster relationships with housing agencies and permanent housing providers, including supportive housing providers.

2. Partner with housing agencies/departments and providers to offer the ECM member permanent, independent housing options, including supportive housing.

3. Provide Individual Housing and Tenancy Support services, including series that support the member become a successful tenant in their housing arrangement, sustain tenancy, and end homelessness.

DOCUMENTATION AND RECORD KEEPING:

1. Complete and become proficient in each MCP provider’s Electronic Health Record to ensure documentation is accurate and in compliance with regulatory requirements and accreditation standards.

2. Maintain documentation for each contact as instructed and within the program timelines (weekly, monthly, quarterly).

3. Ensure the privacy and security of the PHI as outlined in Step Up’s policies and procedures relating to HIPAA compliance including attending annual compliance training.

4. Ensure completion of the Complex Health Assessment (CHA) for all eligible ECM high-risk members within specified timeframe.

5. Assimilate CHA information into the (SCP) Shared Care Plan/Health Action Plan (HAP).

6. Communicate PHQ9 with members, approved family or caregiver and other members of the care team each month.

TEAM ENGAGEMENT AND SUPPORT, PROMOTE STEP UP’S CORE VALUES AND COMMUNITY RELATIONSHIPS:

1. Collaborate on Member care issues with other STEP UP’S ECM team participants in weekly systematic case reviews and ad hoc case reviews and consult with nurse care manager and or behavioral health care manager before taking any action that is clinical in nature

2. Model the highest ethical behavior in relationship with co-workers, supervisor, members, provider, and colleagues in the community and within Step Up’s ECM.

3. Promote a collaborative and effective working environment with then STEP UP’S ECM by engaging in evidenced based communication strategies (such as Motivational Interviewing) when discussing responsibility/sharing of tasks, effective resolving conflict as they arise and collaborating on member case discussions.

4. Build and maintain a positive working relationship with other community partners and providers.

5. Model commitment to continuous quality improvement by engaging in quality improvement initiative and projects such as by identifying and assessing gaps and by identifying, developing and testing new practices for improving the outcomes of the ECM program.

6. Participate in staff meetings, trainings, individual supervisions, and other activities as needed or directly by the STEP UP’S ECM management team.

7. Any other duties as required to ensure HHP operations are successful

SKILLS: Highly skilled interpersonally, with excellent relationship skills. Knowledgeable and skilled in Evidenced based communication such as MI or similar empathy-based communication strategies. Understanding of and sensitivity to mental health conditions and addictive disorders. Understanding of and sensitivity to multi- cultural communities. Awareness of the impact of unmitigated bias, and judgement on health; a commitment to addressing both. Bilingual (English Spanish preferred). Understanding of, and a commitment to, high preforming team practices. Strong Organizational Skills, computer data entry and other software programs and administrative functions.

QUALIFICATIONS: AA degree or equivalent. Medical Assistant Certification (preferred), Bachelor’s degree from an accredited institution preferred. A valid California driver’s license and clean driving record. A reliable vehicle and valid automobile insurance is mandatory, as automobile travel is required either by personal or company vehicle. Step Up will verify these requirements. A clean report Department of Justice background check. At least 2 years of experience in human services setting or community outreach, customer service, or within a medical office, or a Behavioral Health or Substance Use Disorder program. Knowledge of Utilization Management including referral process, or medical billing.

SUPPLEMENTAL INFORMATION:  Work with people experiencing homelessness whether on the streets, in shelters or other places of habitation or services, may present inherent challenges and difficulties such as: exposure to bed bugs or other infestations, unpleasant smells or odors, individuals who may have poor hygiene or unclean homes due to homelessness, mental health symptoms, or poverty.   Additionally, in working with our members, employees may encounter instances of profanity, sexually explicit or derogatory language, or verbal or physical expressions of anger and trauma. Very rarely do these situations ever escalate to physical contact, and negative or derogatory communication patterns can often be negotiated successfully.   All direct care staff are provided adequate training to develop skills to deescalate crisis situations that may arise and Step Up has established procedural safeguards for all employees to mitigate (but not eliminate) these inherent risks of employment.

PHYSICAL REQUIREMENTS: While performing the duties of this job, the employee is regularly required to sit; use hands and fingers; handle or feel; reach with hands and arms; talk; and hear. The employee is frequently required to walk, balance, stoop, kneel, and/or crouch. The employee must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and ability to adjust focus. Keyboard data entry required.

Step Up utilizes the principles of trauma-informed care and mental health recovery. These principles inform our Core Values of Hope, Wellness, Voice and Choice, Respect, and Collaborative Relationships. As representatives of Step Up, employees agree to adhere to these values in their interactions with members, colleagues, supervisors, and associated community members.

STEP UP CORE VALUES

HOPE – We believe all people have the capacity for positive growth and change. We use hope to inspire and motivate ourselves, our members, our colleagues, and our community.

WELLNESS – We believe in promoting a culture that supports healthy and fulfilling lives. We use a supportive environment to foster well-being for ourselves, our members, our colleagues, and our community.

VOICE AND CHOICE – We believe in the right to choose and be heard. We use voice and choice to create meaningful outcomes and empowerment for ourselves, our members, our colleagues, and our community.

RESPECT – We believe in promoting interactions that are non-judgmental, transparent. We use respect to guide all of our words and actions with ourselves, our members, our colleagues, and our community.

COLLABORATIVE RELATIONSHIPS – We believe in forming partnerships to share resources, knowledge, and experiences. We use collaborative relationships to strengthen accomplishments for ourselves, our members, our colleagues, and our community.

Step Up is committed to providing quality services that adhere to the highest ethical standards and principles. All Step Up employees agree to adhere to the ethical policies and codes of conduct, as outlined in the Employee Handbook and those specified for this grant.

Step Up provides equal employment opportunities without regard to age, ancestry, color, creed, mental or physical disability, marital status, medical condition, national origin, race, religion, sex, sexual orientation, veteran status, or any other consideration made unlawful by federal, state, or local laws.

STEP UP IS AN EQUAL OPPORTUNITY EMPLOYER