Social Services Care Coordinator For ECM (Full-Time)

ORGANIZATION

The mission of Ravenswood Family Health Network (RFHN) is to improve the health of the community by providing culturally sensitive, integrated primary and preventative health care to all, regardless of ability to pay or immigration status, and collaborating with community partners to address the social determinants of health.

POSITION SUMMARY

The Social Services Care Coordinator for Enhanced Care Management (ECM) will provide a wide range of case management services for the California Advancing and Innovating Medi-Cal (CalAIM) initiative. Under the administrative direction of the Senior Manager of Social Services, Manager of Social Services, and the Integrated Behavioral Health and Social Services Director, the Social Services Care Coordinator for ECM is a key staff member in the development of collaborative treatment care management plans with patients which support patients' needs in the areas of physical health, mental health, substance use disorder (SUD), community-based long-term services support, social supports, and the patients' social determinants of health. The Social Services Care Coordinator for ECM is responsible for comprehensive case management assessments, care coordination, outreach and engagement, identification of patient support needs, referrals to community social supports, and fostering patients' autonomy and independent skills. This position works closely with the Senior Manager of Social Services.

DUTIES AND RESPONSIBILITIES

To be performed in accordance with RFHN Policies and Procedures

• Serves as the primary contact to enrolled ECM members and advocates to help them navigate the healthcare system.
• Performs patient outreach and engagement in diverse community settings, including street-level outreach; completes all ECM enrollment documents with members in their home, in clinic, or in the community.
• Maintains compliance with all applicable county, state, and federal laws and regulations, and funder and program requirements, including maintaining timely accurate documentation in EPIC and Health Plan Electronic systems.
• Carries an active caseload that varies between 30-40 cases depending on patient acuity.
• Completes patient outreach within the designated timeframe upon receiving the referral, as specified by the member's health plan.
• Monitors the implementation of the care plan and makes updates as needed.
• Develops a Care Management Plan that incorporates patients' needs in the areas of physical health, mental health, SUD, community-based long-term services support, oral health, palliative care, social supports, and social determinants of health.
• Supports patient engagement in treatment, including scheduling appointments, appointment reminders, coordinating transportation, accompanying patient to critical appointments, identifying and addressing other barriers to patient's engagement in treatment.
• Ensures regular contact with the patient and their family member(s), guardian, caregiver, and/or authorized support person(s) as part of care coordination.
• Engages and helps patient to participate in and manage their care; educates members on self-management skills through harm-reduction approaches and motivational interviewing.
• Supports/encourages patients in strengthening their skills to identify and access resources to assist them in managing and prevention of chronic conditions.
• Provides transitional care for patients during discharge from a hospital, and coordination of care to provide adherence support and referrals to appropriate resources and community supports as needed.
• Assists patients in accessing additional benefits and related documentation, such as Social Security Insurance (SSI), CalFresh, cash aid, and obtaining required documentation to apply (ID, birth certificate, immigration status, financial records, marriage/divorce records, proof of medical conditions, etc.).
• Maintains up to date adequate documentation necessary for the collection of data and statistics pertaining to program outcomes, demographics, and information as required by funders.
• Consults with medical and mental health providers and participates in case conferences to assess the patient's mental and physical status and health.
• Establishes program policies, procedures, and standard work guidelines.
• Attends, participates, and reports status of program activities during 1:1 meeting with supervisor, and at other meetings as requested by supervisor.
• Brings urgent/critical issues to supervisor's attention with a sense of urgency.
• Performs other related duties as assigned by supervisor.