ECM Care Coordinator at Path of Life Ministries – RIVERSIDE, California

Location:

Community Shelter

FLSA Status:

Non-Exempt

Department:

Enhanced Care Management

Reports To:

ECM Program Supervisor, RN

Job Status:

Full-Time 40 Hours Per week

Schedule:

4/10, Monday-Friday, rotated for coverage

About Path of Life Ministries

Path of Life Ministries (POLM) is a 501c3 organization serving those experiencing homelessness in the greater Riverside area. Our strategy is to provide a holistic system of care in an integrated, seamless manner to individuals and families, leading them from a place of crisis to a life of stability and self-sufficiency. Our goal is to walk people home. We seek talented and compassionate individuals able to thrive in a high-capacity and complex landscape of providing human services in a non-profit setting.

Position Overview

The Care Coordinator role is a client-facing, field-based role within community-based care management. This position is responsible for actively engaging with populations of focus to provide comprehensive care, ensuring clients are enrolled, monitored, and supported effectively as part of our Enhanced Care Management (ECM) program, under the direction of the RN Program Supervisor. The ECM team provides care management to POLM program participants who are also IEHP members. This service is a Medi-Cal benefit offered to those with complex needs.

This is a non-clinical role requiring adherence to and application of evidence-based practices, knowledge of client and service barriers as well as social determinates of health, and provision of appropriate service coordination to foster holistic health in the populations of focus. The Care Coordinator helps to navigate health care services and systems, promotes health and preventative care, and works closely with the clients’ care teams.

Essential Functions

• Conducts outreach to identify and connect with populations of focus, assessing their needs and eligibility for ECM services and coordinating appropriate services.
• Carries a case load of ECM participants (clients/patients), as assigned by the Program Supervisor or a designee.
• Provides care coordination and connection to services and social support for ECM participants, including appointment scheduling and referral management.
• Works with clients at varied tier levels based on the clients’ needs, and conducts face-to-face visits as determined by those needs.
• Serves as a primary point of contact for clients, establishing and maintaining strong relationships to encourage ongoing engagement in medical care, behavioral health services, and social support services.
• Supports the Registered Nurse Care Manager (RNCM), Behavioral Health Care Manager (BHCM), and the Community Health Worker (CHW) with delegated tasks.
• Consults with the RNCM and/or the BHCM for all clinical needs of clients/patients.
• Uses relationship-based strategies and motivational interviewing to engage clients in their care.
• Connects ECM participants to needed community/social support services by initiating insurance-specific and other community support referrals.
• Assists with the coordination of appointments and referrals for physical and behavioral health needs.
• Assists with arrangements such as transportation, directions, and completion of requests for durable medical equipment.
• Ensures smooth transition of care by coordinating with hospitals and facilities regarding client/patient admissions/discharges.
• Tracks and ensures all required assessments and screenings are performed, including the Comprehensive Health Assessment and the Shared Care Plan (with clinician approval/oversight).
• Engages with members, both in-person and on the phone, using evidence-based approaches (including Motivational Interviewing) to promote collaboration between clients/patients and their medical/behavioral health care team, and to increase ECM participants’ sense of control over all aspects of their health.
• Utilizes evidence-based practices in understanding service barriers, including social determinants of health.
• Provides clients/patients with guidance to navigate healthcare systems and services, promoting health and preventative care.
• Collaborates closely with the client’s/patient’s Care Team (physicians and others) to ensure cohesive service delivery and advocacy.
• Maintains accurate and complete documentation and reporting of interactions and service coordination efforts, along with client/patient engagement and disengagement.
• Supports clients in overcoming barriers to care and accessing necessary resources.
• Remains aware of current services offered by other services providers.
• Maintains strict confidentiality in accordance with agency policies.
• Tracks clients’ information, schedules, files, and forms.
• Tracks clients’ attendance at appointments and initiates outreach and missed appointment procedures, as necessary.
• Collaborates on client/patient care issues with other care team members, participating in Systematic Case Reviews (SCRs) and ad hoc case reviews.
• Participate in ECM Team meetings and other activities.

NOTE: This job description is not intended to be all-inclusive. Employee may perform other related duties as negotiated to meet the ongoing needs of the organization.

Path of Life Ministries is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities.

Education and Qualifications

• Two (2) years in a service setting, health or social services preferred
• Experience preferably in an HMO or Managed Care Setting
• Successful experience working in a team environment
• Excellent relational skills
• Excellent communication skills
• Excellent data entry skills
• Experience with electronic health documentation preferred
• Ability to work with a diverse population of people experiencing homelessness
• Bilingual (English/Spanish) preferred
• Bachelor of Science (BS) in Health Care Management or related field preferred

Requirements Include

• Reliable personal (not public) transportation available for occasional errands. Mileage will be reimbursed.
• Must possess a valid California Driver's License, have a minimum of three (3) years of licensed driving experience, and maintain an acceptable driving record as verified by the DMV.
• Proof of Automobile insurance.
• Employment eligibility verification.
• Successful completion of background screening.

Work Schedule Requirements

• Work schedules are subject to change, or start and end times may vary based on business needs and operational requirements.
• Flexibility and adaptability are essential to meet the demands of the role and the organization.

Physical & Mental Demands

• Ability to multi-task and stay focused with many interruptions
• Ability to stay composed in difficult situations
• Work is performed in both office and field settings, including in clients’ homes and community-based locations
• Regular travel within Riverside County required
• Lifting and carrying up to 25 lbs. for short distances