Coordinate and navigate various services and aspects of chronic disease, primary care, behavioral and mental health and social determinants of health centers and aid those members as needed.

Duties/Responsibilities:

• Take initiative in instituting care coordination policies and communicating with members and providers.
• Assist with enrollment into applicable assistance programs (such as Medi-Cal or Covered CA), preregistering members with health plans and connect members to resources within BHS and in the community.
• Complete ECM assessment and care plan for members.
• Serve as the main point-of-contact for member intake into care management services offered by BHS ECM members.
• Must be available for consultations for high-acuity members at any one of the BHS outpatient sites.
• Oversee intake, transfer of care and discharge activities for members enrolled in specialty care management.
• Provide care management of specialty referrals and linkages to and from community-based partners and other needed services related to a given program/member.
• Communicate regularly with members and their families/support systems about plans of care and protocols.
• Answer members’ questions about their care, care plans, and all other issues so they feel safe and secure while receiving our services.
• Monitor and adjust member care plans based on changing needs and conditions.
• Coordinate referrals related to ECM member needs to and from BHS and providers.
• Address any member concerns with appropriate BHS/ECM staff.
• Coordinate case coordination with relevant care providers and resources.
• Report all care management activities and outcomes to executive management.
• Maintain and foster relationships with community providers, agencies and organizations involved in care transitions and continuity of care for members.
• Works collaboratively as a team member with all staff members.
• Promote and believe in BHS mission statement.
• Other duties as assigned.

Required Skills/Abilities:

• Possession of current California Driver’s License.
• Ability to relate to the public regardless of racial, ethnic, economic, sexual orientation, and gender identity status.
• Ability to work independently and as part of a team.
• Ability to demonstrate/convey respect for cultural and lifestyle diversities of members and staff.
• Ability to present to diverse communities/populations, at all levels of internal/external organizations.
• Ability to recognize personal issues that may have an impact on job performance and interactions with members.
• Ability to note documentation in electronic medical record system(s).
• Strong verbal and written communication skills.
• Proven track record of, and ability to demonstrate ethical and professional standards of behavior.
• Basic knowledge of referrals, both in and out of the healthcare system.
• Basic knowledge and Experience in utilizing Microsoft Office, specifically MS Word and Excel.
• Ability to speak, understand, and read Spanish (preferred), especially Medical Spanish.
• Knowledge of behavioral health and 12-Step/recovery resources in the community (preferred).

Education and

Experience:

• High School diploma, GED or equivalency.
• Associate’s degree or higher in healthcare or a related field (will consider experience in lieu of degree)
• Experience using behavioral strategies including motivational interviewing and self-management support.
• Experience working for a community agency, with Medi-Cal (Medicaid) and Medicare, or underserved patient communities in a healthcare setting.

Desired Education and

Experience:

• Bachelor’s degree in healthcare or a related field.
• Experience participating in Patient Centered Medical Home (PCMH) model of care.
• Experience working in drug and alcohol dependency or behavioral health.
• Experience developing assessments and care plans.

Physical Requirements:

• While performing the duties of this job, the employee is regularly required to stand, sit, talk, hear and use hands and fingers to operate a computer and telephone keyboard reach.
• Light to moderate lifting is occasionally required (up to 25 lbs.)
• Ability to sit at a desk and computer terminal for an extended period of time.
• Ability to move about the facility.
• Vision, hearing, manual dexterity and eye-hand coordination must be adequate for performance of job duties.

The above statements reflect the general duties considered necessary to describe the principal functions of the job as identified and shall not be considered as a detailed description of all the work requirements which may be inherent in the position.