Care Coordinator

Job Description

Job Description

POSITION SUMMARY

The Care Coordinator serves as a vital link among the Operations Department, the Wellness Department, Care Integration, and the Medical and Behavioral Health Team. This role is responsible for coordinating all system-of-care services for patients and collaborating with case managers to implement individualized care plans that address social, economic, academic, familial, cultural, medical, behavioral, and other issues affecting the patient’s functioning and well-being, particularly for families. All services are designed to enhance the health and well-being of women, men, children, and families, and this role serves as a wraparound interdisciplinary team member to support patient care, provide essential outreach and case management, coordinate internal and external services, and ensure high-quality outcomes. Knowledge of local resources and familiarity with comprehensive care plans that address patients' multifaceted needs, including social, economic, and cultural factors, will be essential to the success of this position.

Essential Duties, Functions, and Responsibilities

• Serve as the initial and primary contact with patients of the CalAIM Operations Department programs and services (e.g., Medical Services, Behavioral Health, Nutrition & Wellness Services, etc.).
• Connects patients to needed resources and provides direct linkages to those programs by assisting with navigating various internal and external services.
• Understand patient care plan components in relation to respective program or curriculum, to facilitate needed services, manage internal and external referrals, and ensure good outcomes.
• Participate in community outreach efforts to raise awareness and improve early access to CalAIM Services, Medical Wellness Services, Wellness, Behavioral Health, SUDs, and other Health Education and Social Care needs.
• Complete filing and data entry related to screenings, assessments, and established care plans into the Electronic Health Record.
• Support monthly data reporting requirements by collecting, inputting, tracking, and compiling data into required systems and software.
• Access patient case notes and encounter health record data from electronic Health Record and / or for reporting and outcome tracking.
• Manage assigned internal and external Care Coordination tasks and data tracking for CalAIM Team (e.g., internal and external referrals for additional services and / or resources).
• Maintain an up-to-date community resource and services directory and identify resources for individuals and families, and provide direct connections and support in navigating services.
• Manage ordering and maintain organization and inventory of program and emergency supplies for patients as needed.
• Maintain filing of completed monthly and annual reports for grant, CalAIM requirements, and organizational requirements, ensuring all documentation is completed and accessible.
• Support transportation needs for patients when necessary to support care coordination and treatment goals by managing patient appointments and van reservations as needed.
• Assist in the setup and breakdown of materials for FAIHP events and activities, as well as completing assigned roles and responsibilities related to scheduled events and activities.
• Assist with any auditing requirements.

MINIMUM REQUIREMENTS :

EDUCATION :

EXPERIENCE :

LICENSE / CERTIFICATIONS :

SKILLS :

A clear background check, drug screen, and negative TB screen are necessary for employment.

FAIHP offers a robust benefits package that includes :