POSITION SUMMARY:

The Justice-Involved (JI) Care Coordinator works with individuals who are transitioning from incarceration. Justice-involved individuals—those who are currently, or have previously been, in jails, youth correctional facilities, or prisons—face a higher risk of injury and death compared to the general population. A care coordinator is a healthcare professional responsible for supporting patients and their families as they navigate each level of care. Care coordinators act as liaisons between patients, providers, community clinics, case managers, and hospitals. They assist patients in connecting with the appropriate programs or facilities for their needs, advocate on their behalf, and ensure all parties have the necessary patient information. Care coordinators are responsible for outreach and engagement efforts, both in person and via phone. They also navigate individual members’ program eligibility, including insurance and specifically Medi-Cal eligibility. All staff within these programs are also expected to support other team members in coordination with the program manager or director.

Position Duties and Responsibilities:

• Function as a supportive member of an interdisciplinary healthcare team, using an integrated care and treatment approach.
• Provide education, outreach, case management, and navigational services to qualifying members with the most complex medical and social needs
• Collaborate with individual case managers to connect ECM members with primary care providers (PCP) and related providers as needed to navigate toward health and behavioral interventions that will improve patient health outcomes.
• Responsible for expanding case managers' caseloads by contacting potential members.
• Manage extensive internal and external program referrals, including in-clinic providers, managed care plan referrals, and case manager outreach.
• Reporting member compliance to all managed care plans and consistently meeting reporting deadlines each month.
• Monitor and update online spreadsheets that assist in tracking referrals and documenting patient information
• Verify outdated data and update patient files as needed.
• Ability to interpret various types of information and convert physical documents to digital platforms.
• Ability to develop relationships with Managed Care Plans (MCPs) and their liaisons. You will need to attend monthly meetings and training sessions.
• Stay informed about programmatic updates and new populations added to ECM.
• Participates regularly in Via Care program meetings.

Outreach and Community Mobility:

• Prepare and disseminate program material, find and recruit participants, assess individual and community needs, promote health literacy, and be an advocate
• Community/cultural liaison to Via Care’s Intensive Care Management Services
• Assists patients through the healthcare system by operating as a patient advocate and health systems navigator.
• Coordinates continuity of patient care with external healthcare organizations and facilities.
• Coordinates continuity of patient care with patients and families/caregivers following hospital admission, discharge, and Emergency Department visits.
• Facilitate clients in their comprehensive health self-screenings to collect functional, environmental, psycho-social, employment, housing, educational, and health information, as appropriate as it relates to health outcomes
• Engage families, conduct assessments, suggest referrals, give feedback to case managers, and produce documentation
• Educates patients about the health care system and facilitates relationship-building between the two
• Documents work with patients through appropriate record-keeping that follows the project’s policies and procedures
• Participates/assists as needed in any activities related to the clinic and in collaboration with partners of the clinic
• Attends ongoing training for community health workers/case managers & care coordinators
• Advises patients and others regarding health care and other facilities available to them; assists patients in utilizing services; makes follow-up contacts when required
• Assist in gathering and evaluating data concerning the program to which assigned; may perform incidental clerical duties such as keeping records, answering the telephone, and arranging client appointments
• Other duties as assigned:
• These duties may be modified, and the functions of the job description may be based on the needs of the organization.

Preferred Qualifications:

• History of prior incarceration or lived experience
• Recent experience (last 3 years) working as part of a multi-disciplinary team, collaboratively practicing with PCPs, health workers, health educators, and other health professionals.
• Bilingual English/Spanish
• Valid California driver’s license and excellent driving record
• Verification/Waiver: Verification of qualifying experience, education, and/or training is required at the time of filing. Candidates unable to do so may submit a letter requesting a waiver of this requirement indicating the reason(s) verification cannot be obtained. Failure to submit verification or request for waiver will result in application rejection.
• Excellent verbal and written communication skills.
• Flexible and able to take initiative
• Excellent organization, follow through, and ability to juggle multiple priorities in a fast- paced environment with multiple collaborators
• Demonstrated excellent attendance and reliability
• Able to work flexible job hours (including some evenings and weekends)
• Willingness to work in various environments, including prison/jail settings, street outreach, home visits at SRO, patient’s residence or homeless encampment if applicable to role
• Requires high mobility level to provide outreach at various locations
• Manual dexterity to operate office equipment, including keyboard, copier, telephone
• Must be able to view and work on a computer for a long period of time, ability to use Microsoft office and internet