Case Manager/support Coordinator
3 weeks ago
**SUMMARY**: CALAIM Community Support (CS)is a program supporting unhoused and recently housed individuals funded through California Advancing and Innovating Medi-Cal (CalAIM). It coordinates care by utilizing a person-centered approach to maximizing an individual’s health and life trajectory. All potential CS members must be enrolled in a Managed Care program by Molina Healthcare or Health Net, not the County HFH program. The program will offer the following 3 Community Supports: Housing Transition Navigation Services, Housing Deposits, and Housing Tenancy and Sustaining Services. Step Up is a contracted provider of Community support programs and will receive referrals of qualified members from the managed care programs Step Up. Step Up will begin outreach and engagement to promote the services, enroll the member in the CalAIM- CS, and provide services intended to improve their current housing situation as well as improve their social and physical determinants of health. Members remain in the CS program until they no longer need or want the services. CS services consist of a care team providing in-person support service that aims to identify and manage comprehensive needs through improving outcomes, providing housing support, and addressing social drivers of health.
**Essential Duties**: Primary duties include, but are not limited to, the following:
Under the supervision of the Program Manager, the CS SC I is responsible for working effectively with members and will provide primarily field-based services including: outreach and engagement, housing tenancy and sustaining services, housing transition and navigation services, coordination of care, resource linkages, and working with other professionals and organizations in the community to ensure quality of care for members.
**CARE MANAGEMENT/COORDINATION AND CLIENT CARE SCOPE OF PRACTICE**:
- Participate in outreach and engagement efforts to enroll referred members in CS.
- Housing transition and navigation services.
- Housing tenancy and sustaining services.
- Provide advocacy on behalf of CS Members in the home, the community, and in provider organizations. May transport and attend any appointments to ensure successful completion of and outcomes of each goal.
- Conducting tenant screenings and housing assessments that identifies the member's preferences and barriers related to successful tenancy.
- Developing an individualized housing support plan based upon the housing assessment that addresses identified barriers, includes short and long-term measurable goals for each issue, establishes the member’s approach to meeting the goal.
- Searching for housing and presenting options to the member.
- Identifying and securing available resources to assist with subsidizing rent.
- Identifying and securing resources to cover expenses such as security deposits, moving costs, adaptive aids, environmental modifications, and other one-time expenses.
- Assisting with request for reasonable accommodations.
- Communicating and advocating on behalf of the member with landlords.
- Assisting with arranging for and supporting the member’s move.
- Participate in all formal and informal trainings required by Step Up and external partners.
**DOCUMENTATION AND RECORD KEEPING**:
Complete and become proficient in Healthcare provider’s/Step Up’s Electronic Health Record to ensure documentation is accurate and in compliance with regulatory requirements and accreditation standards.
Maintain documentation for each contact as instructed and within the program timelines and documentation requirements. (documentation is completed within 48 hours of provided services).
Ensure the privacy and security of the PHI as outlined in Step Up’s policies and procedures relating to HIPAA complain including attending annual compliance training.
**TEAM ENGAGEMENT AND SUPPORT, PROMOTE STEP UP’S CORE VALUES AND COMMUNITY RELATIONSHIPS**:
- Collaborate on Member’s issues with other STEP UP’S CS team participants in weekly systematic case reviews.
- Model ethical behavior in relationship with co-workers, supervisor, members, provider, and colleagues in the community and within Step Up’s CS.
- Promote a collaborative and effective working environment with then STEP UP’S CS 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.
- 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 CS.
- Additional coordination with other entities to ensure the member has access to supports needed for successful tenancy.
- Participate in staff meetings, trainings committee meetings and other activities as needed or directly STEP UP or Hea
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