Care Coordinator - ECM Program

About the Role

The Care Coordinator (CC) is a healthcare professional who supports patients and their families through each level of care, functioning as a liaison between patients, providers, community clinics, and hospitals. CCs connect patients with appropriate programs or facilities, advocate on their behalf, and ensure all parties have the necessary patient information. This role involves outreach and engagement both in-person and telephonically, as well as navigating individual members' program eligibility, including insurance and Medi-Cal eligibility.

Responsibilities

• Operate as a supportive role within an interdisciplinary healthcare team using an integrated care and treatment model.
• Provide education, outreach, case management, and navigational services to qualifying members with complex medical and social needs.
• Collaborate with case managers to connect ECM members with primary care providers (PCP) and related providers to navigate health and behavioral interventions.
• Increase case manager caseloads by outreaching potential members.
• Handle internal and external program referrals, including in-clinic providers, managed care plan referrals, and case manager outreach.
• Report member compliance to managed care plans and meet monthly reporting deadlines.
• Monitor and update online spreadsheets for tracking referrals and documenting patient information.
• Verify and update outdated data in patient files.
• Transfer hard copy information to digital platforms.
• Establish relationships with Managed Care Plans (MCPs) and their liaisons.
• Participate in monthly meetings and training courses.
• Stay updated with programmatic changes and new populations of focus added to ECM.
• Participate regularly in Via Care Program Meetings.
• Prepare and disseminate program materials, recruit participants, assess community needs, promote health literacy, and advocate for patients.
• Act as a community/cultural liaison for Via Care’s Intensive Care Management Services.
• Assist patients through the healthcare system as a patient advocate and health systems navigator.
• Coordinate continuity of patient care with external healthcare organizations and following hospital admission, discharge, and Emergency Department visits.
• Facilitate clients in comprehensive health self-screenings to collect functional, environmental, psycho-social, employment, housing, educational, and health information.
• Engage families, conduct assessments, suggest referrals, provide feedback to case managers, and produce documentation.
• Educate patients about the healthcare system and facilitate relationship-building between patients and providers.
• Document work with patients through appropriate record-keeping following project policies and procedures.
• Assist in gathering and evaluating program data; perform incidental clerical duties such as record-keeping, answering telephones, and arranging client appointments.
• Advise patients regarding available healthcare and other facilities, assist in utilizing services, and make follow-up contacts when required.
• Attend ongoing training for community health workers, case managers, and care coordinators.
• Perform other duties as assigned, which may be modified based on organizational needs.

Skills

• Excellent verbal and written communication skills.
• Flexibility and ability to take initiative.
• Strong organization, follow-through, and ability to manage multiple priorities in a fast-paced environment with multiple collaborators.
• Demonstrated excellent attendance and reliability.
• Manual dexterity to operate office equipment, including keyboard, copier, and telephone.
• Ability to work on a computer for extended periods and proficiency in Microsoft Office and internet use.