About Job

SUMMARY

The Enhanced Care Coordinator will work with members to coordinate comprehensive care among various service providers. The ECM Coordinator works as part of an interdisciplinary team to address the member’s physical and mental health, substance use, social needs, oral health, and long-term services and supports. All services are provided in person, with minimal exclusion. The ECM Coordinator primary responsibility requires outreach and engagement of new clients, comprehensive assessment, development of care management plan, coordination of care, health promotion, transitional care services, family supports, and coordination of community and social supports. The ECM Coordinator position requires excellent customer services skills, people skills, and is expected to use Evidence Based Practices, such as Motivational Interviewing and Harm Reduction Model to maintain high quality services. This person is required to build strong relationships with internal programs serving the same clients and our external partners and service providers to ensure clients receive the best care possible.

ESSENTIAL DUTIES & RESPONSIBILITIES

Client Care

Conduct outreach when first assigned a member to establish rapport, including family engagement when applicable.
Provide culturally and linguistically appropriate communication and information to engage members.
Conduct a comprehensive assessment to determine areas of need.
Collaborate with clients on developing a person-centered, individualized service/treatment plan
Meet with client in their homes and/or community. When an in-person session is not possible, meet with client on the phone or via telehealth as appropriate.
Identify clinical and non-clinical resources to address clients’ gaps in care.
Organize clients’ care activities and collaborate with other members of the team regarding the care plan
Ensure that client has an assigned PCP and accesses care consistently
Ensure integrated care among all service providers by following up with primary care physical and developmental health, mental health, SUD treatment, Oral health, and necessary community-based and social services, including housing as needed.
Provide appointment reminders to clients, coordinate transportation, accompany critical appointments, and identify and address barriers to engagement in treatment.
Support members in developing skills to identify and access resources to assist in managing their conditions
Support clients in transitional care services from one setting or level of care to another, including discharges from hospitals, institutions, and other acute care facilities to home or community-based settings.
Engages with the family members to the appropriate extent to assess for services and involve in treatment.

Documentation

Facilitate intake paperwork.
Complete initial assessment and bi-annual reassessment.
Complete Client Care Plan and revise as necessary.
Maintain proper records on case management and/or other activities as instructed utilizing the appropriate Electronic Health Record (EHR).
Enter case notes within 24 hours of service.

Other

Work collaboratively with other provides to ensure appropriate levels of treatment/support.
Communicate clients’ needs and preferences in a timely manner to the clients’ multi-disciplinary care team.

RESPONSIBILITIES COMMON TO ALL AGENCY EMPLOYEES

Always maintain a safe work environment and confidentiality
Be proactive, creative, and flexible in determining, evaluating, researching, and resolving issues
Organize and prioritize multiple activities to meet all external and internal deadlines
Maintain professional demeanor that reflects positively on the agency
Demonstrate respect and courtesy toward others
Able to thrive in a work environment emphasizing teamwork and collaboration
Respond in a timely manner in all aspects of communication
Work with minimum supervision
Perform other duties as assigned

QUALIFICATIONS

Fluent in Spanish required.
2 years of experience working with the unhoused population preferred.
1-2 years of experience working with the unhoused and / or low and mixed- income populations in addition to experience in child welfare, family work, and substance abuse preferred.
Have an understanding of low-income and unhoused individuals and their specific needs preferred.
Knowledge of crisis prevention, intervention, goal setting.
Proficient skills in Microsoft Office, including Microsoft Word and Excel.
Excellent customer service, communication and problem-solving skills.
High quality organizational skills.
The ability to work well under deadlines and to multitask.
The ability to build relationships and coalitions with the community.
The ability to build partnerships and good relationships with providers and clients.
Excellent verbal and written communication skills.
Excellent critical thinking and problem-solving skills.
All other duties as assigned.

WORK ENVIRONMENT

Field and indoor office environment
Will necessitate working in busy and loud environments
Will be exposed to elements like cold, heat, dust, noise and odor
May need to bend, stop, twist, and sit throughout the day
Regularly required to walk or drive to different local sites throughout the day
Regularly required to sit, stand, bend and occasionally lift or carry up to 35 pounds
Will necessitate working in busy and loud environments
Will be exposed to elements like cold, heat, dust, noise and odor

Job Type: Full-time

Schedule:

8-10 hour shift required.
Monday thru Saturday.

Application Question(s):

Knowledge of crisis prevention, intervention, resolution techniques preferred.

Experience:

working with the unhoused population: 2 years (Preferred)
working with low and mixed-income populations: 2 years (Preferred)
and in child welfare, family work, and substance abuse: 1 year (preferred)
Lived experience (History of challenges with social determinants of health: housing insecurity, food insecurity, etc.)

License/Certification: