ECM Service Coordinator I - Community Outreac in San Bernardino, California at Step-Up on 2nd Street

JOB TITLE: Enhanced Care Management Service Coordinator I - Community Outreach IEHP/Molina Health

REPORTS TO: Program Manager of IE ECM Programs

HOURS: 8:00AM-4:30PM Monday-Friday

CLASSIFICATION: Non-Exempt

REQUISITION NUMBER: 1820

SUMMARY: As a key part of CalAIM, Enhanced Care Management (ECM) is a 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 the member’s health,

wellness and an umbrella of services related to enrollee’s overall progress of care. Beneficiaries

will have this single SC1 Community Outreach who will strategize care and care services, which

include physical, behavioral, developmental, and social services delivery systems, making

obtaining care effective and efficient. Providing in-person, field-based services, ECM staff will

meet beneficiaries wherever they are — on the street, in a shelter, in their doctor's office, or

at home. Under the supervision of the ECM program manager.

Benefits and What We Offer:

• Opportunities for growth and professional development.
• Generous paid time off (13 paid holidays, 10 days of EPTO, 12 sick days).
• Competitive salary and benefits package. Health, dental, vision, Aflac, and life insurance $25,000.00
• 403(b) retirement plan available on the first day of work. After working 1000 hours, Step Up matches 3% of the 6% the employee contributes.

DUTIES: The following reflects essential functions for this job but does not restrict other tasks

which may be assigned. SCl Community Outreach will be primarily responsible for all UTC

members and new enrollment intakes for IEHP and Molina programs. SCI Community Outreach

is responsible for working effectively with and as part of the Step Up’s ECM program to provide

high quality, effective care management to ECM members. The SC1 Community Outreach | will

provide field-based services within provider guidelines which include outreach and face-to-face

engagement focusing on members’ present health goals, concerns, and needs. The SC1

Community Outreach may address present mental health behaviors and would

coordinate member’s care such as appointment scheduling and referral management, resource

linkages, transportation, and/or durable medical equipment requests. The SC1 Community

Outreach is responsible for collaborating care with the member’s primary care physician (PCP)

and to ensure that both members and PCP participate in the development of care plan and to

strategize and with the ECM interdisciplinary team and management. Additionally, this position

works collaboratively with enrolled members’ families, and other professionals including the

designed care team, health professionals and organizations in the community to ensure quality

of care for members, seamless transition of care, and facilitation of services is expected. SC1

Community Outreach is to use relationship-based strategies to engage members in care as well

as motivational interviewing or similar empathy-based strategies.

SC1 Community Outreach must have strong organizational skills, computer data entry and

other administrative program expertise to submit required documents, visits notes, care

plans, demographics, legal documents and other mandatory files into provider portals and Step

Up program systems on time and daily. In addition, SC1 Community Outreach | will be able to conduct

basic health data and submit health outcomes such as labs, discharge plans and other health related

records. The SC1 Community Outreach is a mandated reporter and advocates for the

health, protection and safety of the enrolled member.

Leadership, Administration, Oversight

Complete and become proficient in each Healthcare Plan’s Electronic Health Record to

ensure documentation is accurate and in compliance with regulatory requirements and

accreditation standards.

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.

Direct Service and Support

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

Assist Members in navigating the healthcare system, helping Members

successfully participate in their medical and/or behavioral health care by overcoming

barriers to care, sharing information on barriers with the PCP to improve care and

outcomes. These activities are provided by field-based outreach.

Assisting with members’ transition upon discharge from medical or psychiatric hospitals.

By coordinating with hospital discharge planning, being supportive in plan transitions.

Collaborating within the hospital to connect with members before they are released can

start the relationship building that is important for the SC1 Community

Outreach’s success in member engagement.

Navigating housing, routinely revisiting the care plan, and supporting members in

attending follow-up appointments

Play a key role in crisis response teams that provide community-based alternatives to

justice involvement.

Deliver information about health and wellness in ways that the community can easily

understand and provide information on ECM Member benefits and services.

Provide advocacy on behalf of ECM Members in the home, the community, and in

provider organizations.

Transport and attend appointments to ensure successful completion of and outcomes of

each health-related goal or task.

Engage with members in a manner that utilizes evidence-based approaches, such as

motivational interviewing, that promote collaboration between the member and his or

her health.

Assist Step Up ECM and other Providers understand the culture, norms, beliefs and

preferences of the Members and their community by representing the voice of the

community, helping to create messages and materials that fit community culture, and

delivering these messages in a way that fits the culture of Members.

Assist with the coordination of medical and behavioral health access issues with Step Up

programs (not limited to CS, FSP, PSH), PCP offices, and specialists.

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.

Collaborate on Member care issues with other Step Up’s ECM team

in scheduled systematic case reviews and ad hoc case reviews and consult with Nurse

SC1 Community Outreach III, and SCII before taking any action that is clinical in nature

Model the highest ethical behavior in relationship with co-workers, supervisor,

members, provider, and colleagues in the community and within Step Up’s ECM.

Promote a collaborative and effective working environment with the Step Up’s ECM

team 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.

Build and maintain a positive working relationship with members and providers

including by not limited to communication via in-person, over the phone, and through

digital means, such as email and fax.

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.

Participate in staff meetings, trainings, individual supervisions, and other activities as

needed or directly by the Step Up’s ECM team.

Any other duties as required to ensure ECM operations are successful

Locate and work with difficult to engage members

Complete Intake and referral assessments

Identify and submit new member referrals

Documentation and Data Collection

Maintain documentation for each member contact as instructed and within the program

timelines (within 48 hours, weekly, monthly, and quarterly).

Complete CHA: Due immediately upon enrollment, annually, and condition changes.

Obtain members’ Blood Pressures: Due Every 60 days. Updated blood pressures can be

obtained by checking the healthcare plan’s portal, member self-monitoring of their

blood pressure (Per member report or by utilizing ECM staff’s blood pressure monitors

during in-person appointments), or educating members on how to call PCP to obtain

their most recent blood pressure.

Complete member’s PHQ-9: Due every 30 days

Complete Care Plans: Due upon enrollment, and updated Care Plans are due every 90

days.

Transition of Care Discharge (TOC): Due within 7 days of the member’s admission

and discharge from an inpatient hospital stay.

Submitting billable notes to provider portals, Step Up electronic health records

(Welligent) and maintaining member’s charts and profiles.

Keep an accurate and up to date calendar to reflect daily schedule.

Maintaining caseload and census daily

Report emergencies, urgent care needs, crisis, etc. to Step Up management necessary

documentation.

SKILLS: Highly skilled interpersonally, with excellent relationship skills. Knowledgeable and

skilled in Evidenced based communication such as Motivational Interviewing or similar

empathy-based communication strategies. Able to sufficiently engage with members

and healthcare providers in a variety of settings such as on the phone, at member’s homes,

streets if homeless, in hospitals and other health settings. Ability to develop relationships with

community members and leaders, including in the faith-based community. A high degree of

skillful decision-making and judgement, in an autonomous position, including knowing when to

consult with the team, supervisors, and experts. 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. Understanding of, and a commitment to, high

preforming team practices.

QUALIFICATIONS: AA degree or equivalent. 2 years’ experience working in community

outreach, homelessness, and/or a behavioral health or substance use disorder program. A valid

California driver’s license and clean driving record. A reliable vehicle and valid automobile

insurance is mandatory, as automobile travel is required in the Inland Empire either by personal

or company vehicle. Step Up will verify these requirements. A clean report Department of

Justice background check.

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.

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