ECM Care Coordinator

POSITION SUMMARY

Under the general supervision of the Supervising Care Coordinator, the Care Coordinator (CC) works collaboratively with other departments at NVIH to manage a caseload of patients requiring comprehensive and/or complex care solutions, with the ultimate goal of improving health outcomes. The CC provides care management services through various tools and methods, including conducting a patient intake for the Enhanced Care Management (ECM) program, connecting patients with necessary resources, building strong relationships with patients and their families, and following up based on patient needs.

Strong collaboration with clinical care teams and operational teams is essential to ensure a holistic approach to patient support. This position requires effective communication, organizational skills, and the ability to work in a team-oriented environment to fulfill the role's responsibilities successfully. ESSENTIAL JOB FUNCTIONS: The list that follows is not intended as a comprehensive list, but rather to provide a representative summary of the major duties and responsibilities.

Incumbent(s) will be required to perform a variety of duties listed, including but not limited to:

1. Manage individual caseload by conducting comprehensive assessments of patient’s medical, behavioral, and social needs when referred for Enhanced Care Management services.
2. Participate in developing individualized care plans, implementing the services, conducting follow-up, and monitoring the patient’s needs and care plan.
3. Use motivational interviewing and other techniques to support behavior change and adherence to care plan.
4. Coordinate with primary care providers, specialists, behavioral health professionals, and community-based organizations to support a patient-centered approach to care.
5. Provide education and support to patients and their families about managing their health conditions and navigating the healthcare system, while empowering patients to take an active role in their care.
6. Facilitate referrals, navigations, case management services, and linkages to community resources to address patient needs and follow up to ensure services are received and effective.
7. Conduct or coordinate outreach activities in diverse community settings, fostering connections and expanding program reach.
8. Maintain accurate and timely documentation of patients’ assessments, care plans, interactions and outcomes in accordance with regulatory and program requirements.
9. Build and maintain strong working relationships with agencies, organizations, and healthcare providers to advocate for patients and increase program visibility.
10. Assist the team in addressing and resolving escalation concerns from both patients and staff related to the program.
11. Other duties as assigned. All NVIH employees are expected to :

• Provide the highest possible level of service to patients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by current NVIH’s policies and procedures.

REQUIRED QUALIFICATIONS: The following knowledge, skills, and abilities are required for an employee to successfully perform their duties. Bachelor’s degree in Social Work, Psychology, Sociology or related field required. Minimum of one (1) year of experience in a healthcare case management or care coordinator role required; 2 years preferred.

Proficient in reading, interpreting, and supporting complex care plans through critical thinking and sound judgement. Knowledge of clinical medical, behavioral Health and substance use disorder terminology is required. Demonstrated ability to grow and enhance personal and professional skills, as evidenced by achieving subject matter expert status in previous roles.

Strong cross-departmental collaboration and teamwork skills to facilitate patient care coordination activities. Effective written and verbal communication skills, with the ability to speak publicly. Proven ability to engage with underserved communities in a culturally sensitive manner. Ability to effectively work independently with minimal supervision; self-driven to plan workload and accomplish objectives.

Able to travel for training; must maintain a valid California driver’s license, meet agency auto insurance requirements, and have reliable transportation. Advanced computer skills with experience using Electronic Health Records (EHR) systems. Native Preference. Northern Valley Indian Health provides Native Preference in hiring practices for qualified Native applicants, in accordance with its policy.

NVIH is also an Equal Opportunity and At Will Employer

Medical, Dental and Vision Benefits 401k with match 14 paid Holidays 4 weeks PTO Flexible Scheduling