Social Services Medical Care Coordinator - Bilingual

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 Medical Care Coordinator, under the administrative direction of the Senior Manager of Social Services, is a key staff member that will provide vulnerable patients and their families with the resource support needed to achieve their health care goals in outpatient and community settings. The Social Services Medical Care Coordinator will conduct assessments, care plans, perform medication reconciliation, and collaborate with interdisciplinary teams to ensure patients receive holistic and effective care.

This position reports to the Senior Manager of Social Services, but works closely with the Department Manager of Social Services, Social Services Care Coordinators, IBHS staff, Enhanced Care Management (ECM), Medication Assisted Treatment (MAT) Team, pediatrics social worker, and the Health Care for the Homeless (HCH) Manager.

DUTIES AND RESPONSIBILITIES

To be performed in accordance with RFHN Policies and Procedures

• Collaborates with ECM, MAT, HCH, IBHS, and other RFHN care teams to develop appropriate care management plans based on patients' and their families' medical, social and mental health needs.
• Conducts thorough assessments to evaluate the medical and social needs of Social Services patients.
• Collaborates with Care Coordinators to develop and implement tailored care plans that address the unique medical needs of RFHN patients.
• Assists with Durable Medical Equipment (DME) orders for Social Services patients, ensuring they are processed efficiently and effectively.
• Facilitates transitional care planning to ensure seamless transitions for Social Services patients moving between different levels of care.
• Participates in discharge planning processes to prepare patients for successful transitions back into community setting.
• Provide patient education about their health conditions.
• Facilitate engagement between patient and their primary care providers and specialists to ensure continuity of care.
• Works closely with interdisciplinary teams, including social workers, care coordinators, medical providers, nurses, behavioral health staff, among other specialties to ensure comprehensive patient care.
• Attends, participates in, and reports status of program activities at 1:1 meeting with supervisor and other meetings as requested by supervisor.
• Visit patients' homes or in the community to complete medication reconciliation, ensuring accurate and complete medication lists for Social Services patients.
• Brings urgent/critical issues to supervisor's attention with a sense of urgency.
• Documents comprehensive progress notes in a timely manner in the patient's health care record.
• Maintains compliance with all applicable county, state and federal laws and regulations, funder and program requirements, including maintaining timely accurate documentation in EPIC and Health Plan electronic systems.
• May carry a small caseload depending on program needs.
• Other duties as assigned and requested.