Outreach Care Coordinator
Summary
The Outreach Care Coordinator will support and promote LACHC's mission to follow Christ by loving and serving our neighbors through comprehensive, quality healthcare. The OCC will serve as a Lead Care Manager for the Medi-Cal Enhanced Care Management (ECM) program.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Assess, organize, and initiate partnership activities to enhance services provided to current and potential patients.
Represent the organization at community and faith-based events and activities.
Attend community meetings, such as coalition and advocacy meetings, community updates, case conferencing, etc.
Build and maintain positive working relationships with community partners.
Conduct street outreach on a weekly basis.
Use effective communication skills such as active and reflective listening to build rapport with vulnerable and difficult-to-engage clients.
Use evidenced based outreach strategies to locate clients and link them to care.
Motivate patients to be active and engaged participants in their health.
Assist patients with scheduling appointments and assisting with completion of registration paperwork for patient care.
Supply or obtain necessary items, such as hygiene kits, clothing, blankets, etc.
Assess supply needs for patient population and strategize resolution.
Organize, promote, and track in-kind donation initiatives for Care Coordination.
Utilize, maintain, and update LACHC resource guide as changes occur and keep resource information on-hand to give to clients for all applicable resources.
Conduct outreach and enrollment calls to eligible patients for ECM.
Ability to work in groups as well as self-guided, independent outreach and coordination.
Demonstrable experience and understanding of coalition building and nonprofit advocacy, engagement with relevant initiatives, and briefings to departmental leadership.
Care Coordination
Apply evidence-based interventions, such as motivational interviewing and harm reduction, to decrease or prevent complications and optimize patient well-being.
Promote self-management skills for each client to achieve self-directed, individualized health goals that promote recovery, improved functional and/or health status, and/or prevent or slow declines in functioning.
Engage in care coordination activities as indicated, which may include:
- Monitor and encourage treatment plan adherence.
- Manage referrals, coordination, and follow-up for services and supports.
- Ensure appropriate care at level of care transitions by providing evidence-based transition planning.
- Assist clients with linkage and access to vital and appropriate resources per eligibility status, such as: Housing; Substance abuse treatment; Mental health care; and Public benefits.
Afford immediate assistance to patients as needed, including locating emergency shelter, food resources, etc.
Apply Harm Reduction strategies to engage with clients, including participation and certification in Narcan training.
Provide accompaniment services to clients as needed, determined by patient assessment and interviews.
Utilize strengths-based, solution-focused strategies to assist patients.
Create SMART goals in collaboration with patients.
Other Duties as Assigned
QUALIFICATIONS
CPR Certification required.
Bi-lingual Spanish preferred.
Two years of case management experience is required.
Bachelor’s degree in social work or related field from a four-year college or university is preferred.
Prior experience working with individuals experiencing homelessness, substance use, physical health conditions, mental health conditions.
Experience with Electronic Health Records, Microsoft Word, Microsoft Access, and Microsoft Excel is preferred.
Experience with HMIS and CHAMP databases preferred.
Familiarity with medical terms and operations of clinics is useful.
Proficiency in English required, Bi-lingual/ Bi-literal Spanish is preferred.
Ability to calculate figures and amounts such as totals, proportions and percentages.
Reasoning Ability Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Ability to independently make decisions in high-pressure situations.
Physical Demands
Sit and talk or hear.
Use hands to finger, handle, or feel.
Stand; walk; reach with hands and arms; climb or balance; and stoop, kneel, crouch, or crawl.
Lift and/or move up to 10 pounds.
Close vision and ability to adjust focus.
Work Environment
Exposure to carriers of contagious diseases.
Deal with irate and irrational clients who may or may not be under the influence of mind-altering substances such as cocaine, marijuana, alcohol, etc.
Access to patient charts which contain confidential information about medical conditions and other personal matters.
Display a commitment to maintaining patient confidentiality at all times.