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. As Lead Care Manager, the OCC is responsible for maintaining all biopsychosocial care management services for enrolled patients, including strategies to address medical, behavioral, social, and long-term services and supports needs. In addition to individual care coordination, the OCC engages in initiatives designed to promote the organization and its services to the community and promote new patient outreach and enrollment.

ESSENTIAL DUTIES AND RESPONSIBILITIES include:
Community Outreach:

• 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:

• Maintain a patient caseload consisting of ECM participants.
• 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.
• Provide culturally appropriate health education on condition-related topics, such as nutrition, disease management, and treatment compliance.

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.
• Assisting 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.
• Assist with documentation and identification needs.
• Assist clients with locating and obtaining transportation to/from appropriate medical and/or social service appointments.
• Expertise in administering structured assessments, including assessments on Social Determinants of Health, to gather, track, and assess client progress.
• Provide 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 :To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions:

• CPR Certification required.
• Bi-lingual Spanish preferred.

EDUCATION and/or EXPERIENCE:

• 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 homeless, substance use, physical health conditions, mental health conditions.

COMPUTER KNOWLEDGE:

• Experience with Electronic Health Records, Microsoft Word, Microsoft Access, and Microsoft Excel is preferred.
• Experience with HMIS and CHAMP databases preferred.

LANGUAGE SKILLS:

• Familiarity with medical terms and operations of clinics is useful.
• Proficiency in English required, Bi-lingual/ Bi-literal Spanish is preferred.

MATHEMATICAL SKILLS:

• 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:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to sit and talk or hear. The employee frequently is required to use hands to finger, handle, or feel. The employee is occasionally required to stand; walk; reach with hands and arms; climb or balance; and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus.

WORK ENVIRONMENT:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee will be exposed to carriers of contagious diseases. The employee may have to 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.
The employee will have access to patient charts which contain confidential information about medical conditions and other personal matters. The employee must display a commitment to maintaining patient confidentiality at all times.

WORK STATUS:
Equal Opportunity Employer. Willing to consider candidates with criminal histories.

About Los Angeles Christian Health Centers:

Los Angeles Christian Health Centers opened in 1995 with a handful of staff but a big vision to render hope and healing through healthcare to the thousands of homeless and low-income residents living in Los Angeles County. Today, 120 staff members serve the County’s most vulnerable populations from our two full-time health centers in Skid Row and Boyle Heights. We also provide comprehensive medical care at our 10 part-time satellite clinics hosted by our community partners throughout Downtown Los Angeles and Watts.