Outreach Care Coordinator

• 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.

• 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.

• 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.

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

• 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.

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

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

• Ability to calculate figures and amounts such as totals, proportions and percentages.

• 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.

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.