PneumaCare Health and Wellness is dedicated to serving the most vulnerable members of our community by fostering stability and resilience in the areas of Community Supports, Enhanced Care Management and Day Habilitation. We are supported by the mission of the Ministerial Association of Colusa County (MACC), our mother organization, by partnering with the local church to empower our communities through the Gospel.

Under the direct supervision of the CalAIM Program Manager, the Community Care Coordinator is responsible for coordinating and implementing Enhanced Care Management (ECM) and Community Supports Management. Overseeing and implementing provision of the Enhanced Care Management and CS services; and identification and achievement of Plan goals and objectives with the member that meet their self-identified strengths and health care and psychosocial needs.

Job Description involves, but is not limited to:

• Engages eligible members, offers services where the member lives, seeks care, or finds most easily accessible and within health plan guidelines.
• Oversee provision of services and implementation of the Care and/or Housing Plans.
• Connects with ECM member via phone or in-person to facilitate engagement, assessment, follow-up, and education/training visits in order to develop and address the Care and/or Housing Plans.
• Works in conjunction with member to identify Plan goals and objectives.
• Connects member to other Community Supports, social services and supports he/she may need.
• Accompanies member to office visits, as needed and according to health plan guidelines.
• Arranges transportation and responsible to convene care conference meetings, while Coordinating with resource partners to obtain data/information to ensure accurate Plan updates.
• Utilize Case Documentation systems and other electronic tracking systems to coordinate services and input data for reporting.
• Attends required trainings. Facilitates internal trainings/updates to clinical and administrative staff members.
• Collaborates with Program Director to ensure ECM templates are appropriate and effective at capturing needed data/information.
• Reviews existing MACC protocols and polices to match requirements. Develops new protocols, policies, and accompanying workflows.
• Assists the required ECM reports and other internal reports.
• Responsible for coordinating with those individuals and/or entities to ensure a seamless experience for the Member and non-duplication of services

• Advocate on behalf of Members with health care professionals

-Uses motivational interviewing, trauma- informed care, and harm-reduction approaches

• Coordinate with hospital staff on discharge plan
• Accompany Member to office visits, as needed and according to MACC and MCP guidelines
• Monitor treatment adherence (including medication)

-Provide health promotion and self- management training

• Other duties as assigned.

KNOWLEDGE, SKILLS AND ABILITIES

• Strong documentation skills.
• Ability to multi-task and prioritize when needed.
• Ability to independently seek out resources and work collaboratively.
• Ability to develop and maintain good working relationships with staff.
• Ability to use computer and learn new software programs.
• Excellent interpersonal skills reflecting clarity, diplomacy, and the ability to communicate accurately and effectively with all levels of staff and management.
• Demonstrates ability to work in a regulatory climate that includes oversight of state and federal entities, payer contracts etc.
• Possesses ability to communicate effectively, both verbally and in writing.
• Proficient knowledge of Microsoft Outlook, MS Word and Excel.
• Able to travel and attend professional meetings, conferences, trainings, and clinic sites.

QUALIFICATIONS

Candidates may qualify for this role through any of the three listed below:

1. Medical Assistant, CNA, or Behavioral Health or Social Services paraprofessional with at least 2 years of case management or related experience in the field.

OR

2. AA in social work, sociology, human services or related fields preferred, 3-5 years of experience providing home health and/or social services case management services to low-income populations with one or more of the following: complex chronic conditions, high utilizer of emergency room and tertiary health care services, severe mental illness, and/or homelessness.

OR

3. Possess a combination of skills and experience relevant to the role, including but not limited to case management, social services, healthcare, mental health support, and homelessness intervention. Candidates may demonstrate their qualifications through a combination of education, certifications, and practical experience in related fields.

NOTE: Candidates with less educational experience will be considered if lived experience is indicated