Care Coordinator

POSITION: Care Coordinator (with CHW duties)

STATUS: Non-exempt; Full time

REPORTS TO: Care Management Program Coordinator

SUPERVISES: None

DEPARTMENT: Performance Improvement

OFFICIAL DUTY STATION: Hybrid - Los Feliz Health Center

SUMMARY:

The Care Coordinator performs essential functions of care management and care coordination as part of the Care Team for the Enhanced Care Management Program. The Care Coordinator manages specified cases, coordinates health care benefits, provides education and facilitates member access to care in a timely and cost-effective manner. The Care Coordinator collaborates and communicates with member, family/support persons, providers, and the Enhanced Care Management Team to promote wellness and member empowerment, while ensuring access to appropriate services and maximizing member benefit. The Care Coordinator serves as a clinical advocate for members, active interdisciplinary team member, liaison with other departments and external health and social service providers. The Care Coordinator is also responsible for providing short-term service plan for the referred client/patients as related to utilization/ follow-up of external community resources.

The Care Coordinator shall also assist in other care coordination programs as assigned by Director of Performance Improvement, including administration of (1) APHCV's Remote Patient Monitoring Program, where he/she will monitor and track distribution of RPM equipment, provide and/or facilitate patient education on the use and care of the RPM equipment, and provide overall implementation coordination of the RPM program; (2) Care coordination of AWV visits for Medicare beneficiary including outreach and appointment scheduling and (3) Care coordination of tobacco cessation services and linkages of care for cessation services.

APHCV expects all employees to respond and participate to emergency situation per emergency policies and procedures.

APHCV requires all staff to comply with Standards of Conduct and Compliance Program related policies and procedures. Such compliance is part of this position's performance evaluation.

DUTIES AND RESPONSIBILITIES:

A. Enhanced Care Management (ECM): 70%

1. Serve as a Care Coordinator function for ECM enrolled members.

2. Conduct Comprehensive Health Assessment to assess member needs in the areas of physical health, mental health, SUD, community-based Long Term Services & Supports, oral health, palliative care, trauma-informed care, social supports, and housing (as appropriate for individuals experiencing homelessness).

3. Oversee provision of Health Action Plan services and implementation of Health Action Plan

4. Connect ECM member to other social services and supports he/she may need

5. Advocate on behalf of members with health care professionals

6. Use motivational interviewing, trauma-informed care, and harm-reduction practices

7. Work with hospital staff on discharge plan

8. Conduct outreach to and engage eligible ECM members to encourage enrollment in the program

9. Monitor treatment adherence (including medication)

10. Provide health promotion and self-management training

11. Arrange transportation

12. Document and submit for claims all ECM related encounters for services rendered.

B. Remote Patient Monitoring Program: 5%

13. Administer Remote Patient Monitoring program for APHCV's Chronic Care Management Program.

14. Monitor, track and report on distribution of RPM equipment

15. Provide and/or facilitate patient education on the use and care of the RPM equipment.

16. Attend and participate in HRSA NHCI program activities.

C. Care Coordination for AWV: 5%

17. Conduct outreach and schedule AWV appointments for APHCV Medicare beneficiaries, both managed care and non managed care.

18. Coordinate referrals for Chronic Care Management services of Medicare beneficiaries.

D. Care Coordination for Tobacco Cessation: 5%

19. Coordinate linkages of cessation services for smokers through ensuring cessation referrals are completed

20. Participate in State Tobacco Cessation program as Care Coordinator and community liaison.

21. Work with other staff to develop, maintain cessation workflow completion.

E. Community Health Worker Duties: 10%. Provide and document in patient chart the following services provided:

22. Navigation services for patients to be able to utilize available resources and health and human services system.

23. Health promotion, education and information.

24. Assistance to have patients receive the services they need

25. Provide patient social support for building individual capacity to help him/herself

26. Follow up with patients so that they complete care, linking to APHCV's service, in-house and external specialists, and outside services.

27. Provide screening and assessment to patients.

28. Individual support or advocacy that assists patient in preventing the onset or exacerbation of a health condition or preventing injury or violence.

F. QUALITY IMPROVEMENTS AND QUALITY ASSURANCE: 5%

29. Participate in various QI and QA activities as assigned.

G. OTHER DUTIES

30. Any other duties CEO and/or DPI might assign.