Care Coordinator for Chronic Care Management

7 days ago

Los Angeles, California, United States JWCH Institute Full time
Job Overview

We are seeking a dedicated Care Coordinator to join our team at JWCH Institute, Inc.

About the Role:

The Care Coordinator will provide comprehensive case management services to patients with multiple chronic conditions, frequent ER visits or inpatient admissions, or those experiencing homelessness.

Key Responsibilities:

  1. Collaborate with healthcare providers, managed care plans, and community service providers to ensure seamless care coordination for eligible patients.
  2. Perform comprehensive case management services, including intake, assessment, personalized care plan development, implementation, subspecialty referrals, monitoring, and follow-up.
  3. Connect patients with essential social and support services, arranging referrals for specialized care, transportation, housing, and more.
  4. Accompany patients to appointments as necessary.
  5. Advocate on behalf of patients with healthcare professionals to ensure their needs are understood and addressed effectively.
  6. Utilize motivational interviewing, trauma-informed care, and harm-reduction strategies to foster positive interactions and promote well-being.
  7. Coordinate with clinical staff to establish well-structured discharge plans, facilitating smooth patient transitions.
  8. Monitor and encourage treatment adherence, including medication regimens, to support optimal health outcomes.
  9. Provide health promotion and self-management training to empower patients in managing their well-being.
  10. Collect and input essential data for reporting purposes, ensuring accurate completion of project activity and monthly reports as required by funding sources.
  11. Engage in agency and community meetings to address patient needs and discuss Case Management-related issues.
  12. Participate in weekly case conferences with PCPs, clinical supervisors, and peers to facilitate collaborative problem-solving for client-related challenges and ensure high-quality case management services.
  13. Collect data for comprehensive initial and ongoing assessments of patient needs, including functional status, housing, mental health, substance abuse, and education.
  14. Regularly update ISPs during weekly client meetings, reporting progress at case conferences to ensure effective goal achievement.
  15. Provide clients with referrals for various services, including HIV care, housing, food, transportation, benefits counseling, mental health, and medical support.
  16. Verify clients' eligibility for public assistance programs, guiding them through steps to access programs such as HWLA, Medi-Cal, SSI, GR, and housing options.
  17. Maintain confidentiality of information related to colleagues and clients.
  18. Participate in designated staff, quality improvement, case conferences, and in-service meetings.
  19. Perform other assigned responsibilities as needed.

Requirements:

  1. High School Diploma or GED.
  2. At least 1 year of experience as a care coordinator, community health worker, or in a similar role.
  3. Experience working with individuals with multiple chronic conditions, frequent ER visits or inpatient admissions, or those experiencing homelessness.
  4. Electronic Health Record experience and data entry skills required.
  5. Proficient in Microsoft Word, Excel, and PowerPoint.
  6. Exceptional verbal and written communication skills.
  7. Proficient in active listening and effective communication techniques.
  8. Demonstrated empathy and understanding when working with clients facing challenging life circumstances.
  9. Sensitivity to and understanding of cultural, social, and economic diversity.
  10. Strong desire to work as part of a multidisciplinary team of care coordinators, LCSWs, MSWs, PCPs, and MAs.
  11. Bilingual (English/Spanish) strongly preferred.

Preferred Qualifications:

  1. AA or Bachelor's degree in Social Work, Sociology, Human Services or a related field.
  2. Medical Assistant with at least 2-3 years of case management experience.
  3. Licensed Vocational Nurse (LVN) with at least 1 year of case management experience.

Benefits:

  • Competitive salary range: $55,000 - $70,000 per year, depending on experience.
  • Monthly employer-sponsored allowance for assistance with health premiums.
  • Funded Health Savings Account (up to deductible) to assist with carrier-approved medical expenses.
  • Paid time off (vacation, sick leave) and 13 paid holidays.
  • 401(k) Safe Harbor Profit Sharing plan.
  • Mileage reimbursement.
  • Short- and long-term disability plans (LTD/STD).
  • Life insurance policy & AD&D, and more

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