Community Care Coordinator

Kaweah Health is a publicly owned, community healthcare organization that provides comprehensive health services to the greater Visalia area in central California. With more than 5,000 employees, Kaweah Health provides state-of-the-art medicine and high-quality preventive services in our acute care hospital, specialized health centers and clinics. Our eight-campus healthcare district has 613 beds and offers comprehensive health services across a broad continuum of care.

It takes a special person to work for Kaweah Health. We serve a region where the needs are great, which makes the rewards even greater.

Every day, we care for people facing unique challenges and in need of healing. Throughout it all, our focus is to make a difference, and we do - in the health of our patients, our loved ones, and our community.

Benefits Eligible

Full-Time Benefit Eligible

Work Shift

Day (United States of America)

Department

8521 PATH CITED

Improves the outcomes and delivery of care to those individuals who have serious unmanaged health and/or psychological conditions and uses health services in ways that do not result in positive health outcomes. Connects high utilizing individuals with available resources in the community to improve their health outcomes, reduce redundant health care utilization, and procure housing in the case of homelessness.

The Community Care Coordinator coordinates the provision of patient care within programs such as Health Homes Program (HHP), Enhanced Care Management (ECM), and In Lieu of Services (ILOS) to ensure patients' care is continuous and integrated amongst service providers. Acts as the lead case manager for patients and will be responsible for the navigation of patient's medical health, behavioral health, social systems, community resources and housing transitions. Involves patients and their family members, the health-care team members and outside organizations to reduce and address Social Determinants of Health (SDOH) and barriers to care.

License /Certification Required:Valid California Driver's License. Must provide DMV report prior to offer being made.

No driving infractions 5 years prior to hire or during time in this job. Infractions include DUI, Suspended or Revoked License, Reckless Driving. Preferred:N/A Education Required:Bachelor's degree in Social Work, Psychology, Behavioral Sciences, Health Education, Public Health or related field, or four years of community outreach experience.

Preferred:N/A Testing N/A Experience Required:N/A Preferred:N/A Knowledge/Skills/Abilities Ability to organize and prioritize work Excellent diplomacy and negotiation skills Good written and verbal skills Must have valid transportation and auto insurance Bilingual in Spanish strongly preferred Preferred working knowledge of social service programs and benefits; laws, rules, and procedures governing eligibility for public assistance programs, basic record keeping practices including client related service documentation, use of electronic office tools; client service engagement and accountability. Department Specific Requirements N/A Essential Conducts outreach, client engagement, referral, treatment, education, data collection, and supportive community-based services for assigned client caseload. Works closely with the Primary Care Provider (PCP) team, Patient and Family Services (PFS), Patient Advocates, Financial Counselors, and the admissions/benefits staff to assist in patient transitions of care and follow up.

Provides insight into the client challenges and barriers based on home visits to the client's care team. Facilitates client access to community resources, including locating housing, food, clothing, school programs, vocational opportunities or services, providers to teach life skills, and relevant mental health services, assists client to develop natural resources and make contact with social support networks. Acts as liaison on behalf of the client and care team; will encourage and enable when necessary patients to go to scheduled appointments.

Responsible for becoming familiar with the services available in the targeted communities in an effort to connect patients and their families with available services.

Advocates for resources and leveraging services to provide a comprehensive, seamless system of health care for targeted patients. Makes home visits to assess needs, follows up on challenges and barriers, provides training to help patients and their families to increase their knowledge of the disease/condition, and the skills and resources necessary to increase their abilities to become more healthy as individuals.

Connects patient with clinical team to provide education relative to medical conditions, nutritional guidance and medication administration. Maintains written documentation, records, files, and statistics according to organizational instructions and job function. Ensures records and files are completed accurately, kept current and maintained in the electronic health record (EHR) CERNER MILENNIUM.

Coordinates and monitors services, including comprehensive tracking of client activities in relation to care plan. Assists clients in developing goals in areas of need and assists in developing treatment plans and health action plans, which are assessed regularly. Meets with leadership as needed for review of activities, priority setting and problem solving.

Keeps Manager informed of progress on projects and special activities. Develops working knowledge of all areas of public assistance, case processing, eligibility, management, community resource contacts. Assesses and evaluates patient social determinants of health (SDOH) challenges and barriers for meaningful and accountable follow through on health care treatment and services.

Acts to develop client self-care abilities, providing tools and education for self-care and self-management of health condition(s) and self-management of social determinants of health challenges. In the ambulatory clinic system, works closely with the LVN Care coordinator, PCP, Medical Assistant, pharmacy team and behavioral health provider to schedule Case Conference as needed. Addendum (essential for specific dept) IF ASSIGNED AS LEAD ALSO RESPONSIBLE FOR:Assists in development and implementation of new employee training.

Supports training new or revised team processes, functions, resources, including specific local clinic assignment related functions. Responsible for scheduling and overseeing students and interns seeking health care setting hours of learning. Recommends and supports development of new resources and tools for the team, in cooperation with the manager.

Participates in planning and implementation, resource, health plan meetings to formulate service plans and give feedback regarding program needs and growth opportunities. IF ASSIGNED TO HEALTH HOMES PROGRAM (HHP), Enhanced Care Management (ECM), In Lieu of Services (ILOS) ALSO RESPONSIBLE FOR:Oversees the provision of services to populations of focus such as high utilization, homeless, severe mental illness (SMI, low to moderate) and implementation of the HAP. Offers services where the member lives, seeks care, or finds the most easily accessible setting within applicable guidelines.

Connects members to other social services and supports he/she may need. Advocates on behalf of members with health care professionals. Uses motivational interviewing and trauma informed care practices.

Works with hospital staff on discharge plans. Engages eligible members for HHP, ECM and ILOS programs. Accompanies enrolled members to office visits, as needed and according to applicable guidelines.

Monitors treatment adherence (including medication). Provides health promotion and self-management training. Arranges transportation. Forms and fosters relationships with housing agencies and permanent housing providers, including supportive housing providers.

Partners with housing agencies and providers to offer the member permanent, independent housing options, including supportive housing. Connects and assists the member to permanent housing when available. Coordinates with the member in the most easily accessible setting, within applicable guidelines.

IF ASSIGNED TO HEALTH NAVIGATOR PROGRAM ALSO RESPONSIBLE FOR:Partners with community resources and agencies to conduct outreach to target populations. Participates in community activities and events to conduct outreach to target populations and establish relationships with target populations for purposes of Medi-Cal enrollment and renewal. Community events and activities may include Street Medicine team outreach, Family Resource Center events, farmworkers activities and others as opportunities for connecting with the target population are known.

Assists target population in collecting documents, submitting application and supporting documents for enrollment. Conducts outreach to the target population regarding timely re-enrollment. Completes program documentation and submit timely record keeping according to organizational and department instructions.

Additional Attends assigned team meetings, which may include local clinic team, department team or other, and participates in discussion. Provides outreach and education in the communities of Tulare County. Transports patients to and from needed locations using a company vehicle.

Assists the primary health clinics in these communities to provide outreach and education to the families they are treating in those areas. In addition, provides education and outreach by visiting patients' homes and neighborhoods. Advocates for resources and services the patients may need.

Works directly with appropriate individuals to determine the educational materials in an effort to develop educational materials that are culturally and linguistically appropriate. Completes various projects and assignments associated with job in a timely manner. Participates as a student in at least one continuing education course offered annually and demonstrates application within the work setting.

As applicable, maintains membership in appropriate professional and community organizations. Demonstrates the knowledge and skills necessary to provide care and services appropriate to the population served on the assigned unit or work area. Performs other duties as assigned. May attend community networking meetings as ass

Pay Range

$23.37 -$35.05

If you want to use your talents alongside people who face each day with courage and purpose, in an environment that empowers you to do your absolute best, this is where you belong.