Job Description
Essential Duties and Responsibilities :
● Engages eligible members
● Offers services where the member lives, seeks care, or finds most easily accessible and within health plan guidelines
● Oversee provision of services and implementation of the Care Plan
● Connects with member via phone or in-person to facilitate engagement, assessment, follow-up, and education/training visits to develop and address the Care Plan.
● Works in conjunction with member to identify Care Plan goals and objectives.
● Connects member to other Community Supports / social services and supports he/she may need.
● Accompanies member to office visits, as needed and according to health plan guidelines.
● Arranges transportation.
● Responsible to convene care conference meetings.
● Coordinates with ECM resource partners to obtain data/information to ensure accurate Care Plan updates.
● Utilizes eCW and other electronic tracking systems to coordinate services and input data for reporting.
● Attends required trainings.
● Facilitates internal trainings/updates to clinical and administrative staff members.
● Collaborates with IT department to ensure ECM templates are appropriate and effective at capturing needed data/information.
● Reviews existing T.H.E.s protocols and polices to match ECM requirements.
● Develops new ECM protocols, policies, and accompanying workflows.
● Assists the required ECM reports and other internal reports.
● Responsible for coordinating with those individuals and/or entities to ensure a seamless experience for the Member and non-duplication of services
● Advocate on behalf of Members with health care professionals
● Use motivational interviewing, trauma- informed care, and harm-reduction approaches
● Coordinate with hospital staff on discharge plan
● Accompany Member to office visits, as needed and according to T.H.E. and MCP guidelines
● Monitor treatment adherence (including medication)
● Provide health promotion and self- management training
● Other duties as assigned.
Required Education and Qualifications:
● Bachelor’s Degree in a healthcare, behavioral healthcare, social work, human services, or related field with one year of experience, preferably in working with patients in a clinic setting, providing home health care for patients, or social services case management services to low-income populations with one or more of the following: complex chronic conditions, high utilizer of emergency room and tertiary health care services, severe mental illness, and/or homelessness.
● Licensed Vocational Nurse (LVN), licensed behavioral health care professional, social worker, substance abuse counselor, health educator, or other similar paraprofessional preferred.
● MPH or related fields preferred
● Bilingual in English/Spanish (oral and written)
Knowledge. Skills and Abilities:
● Strong documentation skills.
● Ability to multi-task and prioritize when needed.
● Ability to independently seek out resources and work collaboratively.
● Ability to develop and maintain good working relationships with staff.
● Ability to use computer and learn new software programs.
● Excellent interpersonal skills reflecting clarity, diplomacy, and the ability to communicate accurately and effectively with all levels of staff and management.
● Demonstrates ability to work in a regulatory climate that includes oversight of state and federal entities, payer contracts etc.
● Possesses ability to communicate effectively, both verbally and in writing.
● Proficient knowledge of Microsoft Outlook, MS Word, and Excel.
● Able to travel and attend professional meetings, conferences, trainings, and clinic sites.
● Performs other related duties as assigned.
Company DescriptionT.H.E. Health and Wellness Centers is a nonprofit community clinic in South Los Angeles. For more than 50 years, we've provided high-quality, low cost healthcare and preventative education for all.
We are an Equal Opportunity Employer.T.H.E. Health and Wellness Centers is a nonprofit community clinic in South Los Angeles. For more than 50 years, we've provided high-quality, low cost healthcare and preventative education for all.\r\n\r\nWe are an Equal Opportunity Employer.
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