Care Coordinator - Behavioral Health CCBHC

Primary Duties:

• Ensures Outpatient Primary Care Screening and collection of complete NOMs measures for all program enrollees, consistent with CCBHC Criteria 4.G., and that completed measures are delivered in a timely and complete manner to Evaluator.
• Ensures CCBHC collects and reports all SAMHSA-required health measures and works closely with CCBHC director to coordinate population health and wellness programs for enrollees, including as required: BMI screening and follow-up; weight assessment and counseling for nutrition and physical activity for children and adolescents; care for controlling high blood pressure; diabetes screening for people who are using antipsychotic medications; diabetes care for people with serious mental illness (HbA1c); metabolic monitoring for children and adolescents on antipsychotics; cardiovascular health screening for people who are prescribed antipsychotic medications; and cardiovascular health monitoring for people with cardiovascular disease and schizophrenia.
• Ensures that children and older adults receive age-appropriate screening.
• Ensures provision of vaccinations where indicated, including for Hepatitis A and B.
• Working with the CCBHC director provides collaboration and coordination with Ryan White HIV/AIDS Program grantees for the provision of HIV care and treatment services, including Hepatitis screening, testing, and vaccination for people living with HIV.
• Supports CCBHC director and Care Coordination Director efforts to establish care coordination expectations with Federally-Qualified Health Centers (FQHCs) to provide health care services, to the extent the services are not provided directly through the CCBHC, including established protocols to ensure adequate care coordination.
• For consumers who are served by other primary care providers, including but not limited to FQHC Look-Alikes and Community Health Centers, works with the Care Coordination Director and CCBHC Director to ensure SCHARP has established protocols to ensure adequate care coordination.
• Consistent with CCBHC Criteria 4K, works closely with Veterans Care Coordinator to ensure Active Duty Service Members (ADSM) use their servicing Military Treatment Facility, and their MTF Primary Care Managers (PCMs) are contacted by the CCBHC regarding referrals outside the MTF.
• Serves as a liaison between patients, family members, and various healthcare professionals.
• Educates patients and their families on health conditions, preventive care, and lifestyle choices.
• Helps patients navigate the healthcare system, including scheduling with specialists, understanding medical bills, and coordinating transportation.
• When needed, accompanies patients to health-related appointments.
• Tracks and facilitates follow-up appointments, ensuring continuity of care and adherence to treatment plans.
• Meets weekly with Project Director to achieve program goals & objectives.
• Attends CCBHC weekly care coordination meetings prepared to provide the team status updates and any SDOH barriers on identified individuals.
• Other duties as assigned

Position Competencies:

• Familiarity with medical terminology and laboratory procedures.
• Excellent prioritization, organizational, oral and written communication, and interpersonal skills.
• Proficient in the use of electronic medical records (EMR) software.
• Bilingual abilities are a plus.

Position Requirements:

• Must have a bachelor's degree or equivalent work experience demonstrating proficiency in high-touch medical case management problem-solving complex social determinants of health and mental health needs.
• Must be experienced working with low income, diverse populations including persons affected by mental illness, substance use and incarceration. Subject to California State Department of Justice criminal background investigation, Live Scan and/or fingerprinting.
• Ability to demonstrate adequate literacy skills to perform work duties will be considered.
• Must have a valid California Driver's license and the availability of a car with adequate insurance

Equal Opportunity Employer
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