Care Coordinator (CTRI) Jurupa Valley, CA

Essential Functions

• Enroll and conduct Comprehensive Health Assessments to finalize ECM member enrollment.
• Collaborate with the member to develop a person-centered Care Plan addressing social needs, physical and behavioral health needs, and member’s personal goals, strengths, and priorities.
• Update the care plan as needs change or milestones are reached.
• Connect members to social resources including housing and shelter programs, transportation services, food and basic needs programs, medical & behavioral health appointments, public benefits, and assist with referrals, appointment scheduling, paperwork, and follow-ups.
• Maintain ongoing outreach and engagement through phone, in-person, and home visits.

Monitoring, Documentation & Case Management

• Maintain regular contact with assigned caseload to support stability and progress.
• Track retention, service completion, care plan goals, and key barriers.
• Document all member interactions in EHR system in real time.
• Monitor engagement and escalate high-risk/complex cases to medical and Behavioral health support team.

Interdisciplinary Team Collaboration

• Participate in weekly case conferences.
• Share progress updates, identify challenges, and adjust care strategies collaboratively.
• Coolcordinate warm handoffs and shared planning with ECM LCM, CHWs, BH CM, and NP.

JOB QUALIFICATIONS

• A Bachelor's degree or higher from an accredited college or university in Health Information Systems, Public Health, Public Policy, Psychology, Social Work, or a related field.
• Experience with researching, studying, and making recommendations to support health or social service programs or policy.
• Bilingual proficiency (English and Spanish) strongly preferred.
• Three (3) years in a highly responsible management experience in program administration for underserved populations preferred.
• Strong organizational skills, including an ability to manage multiple work projects simultaneously, track project details, and meet deadlines.
• Strong technical skills with Microsoft excel and experience with database management (e.g., Electronic Health Record Systems) preferred.
• Ability to attend meetings, provide training, technical assistance, and other job-related duties in locations throughout Southern California and have reliable transportation to carry out essential functions.

Certificates/Licenses/Clearances

• A valid California Class C Driver License or the ability to utilize an alternative method of transportation when needed to carry out job-related essential functions.
• Background clearance to include Livescan and TB test.

Other Skills, Knowledge, And Abilities

• Proficient skill set in using an array of Microsoft Office Suite software programs such as Word, Excel, PowerPoint, Access, Adobe Reader, One Note, Outlook, Publisher, Teams, Outlook, Zoom etc.
• Able to multi-task and set workload priorities for time sensitive projects/tasks.
• Able to problem solve and make recommendations to processes, policies, etc.
• Able to communicate with all levels of personnel, e.g., written, verbal, in a professional and concise/clear manner; ability to work within a project team and/or independently.
• Able to work in a very diverse environment and with diverse individuals.
• Able to be flexible in meeting changing work tasks and timelines; must be dependable and reliable.

PHYSICAL DEMANDS

• Stand Frequently
• Walk Frequently
• Sit Frequently
• Handling / Fingering Occasionally
• Reach Outward Occasionally
• Reach Above Shoulder Occasionally
• Climb, Crawl, Kneel, Bend Occasionally
• Lift / Carry Occasionally - Up to 30 lbs.
• Push/Pull Occasionally - Up to 30 lbs.