ECM and Community Outreach Coordinator

Job Summary:

We seek a reliable and compassionate CHW to provide CHW and ECM services and conduct consistent Community Outreach to clients in the community. As a CHW, you will play a vital role in improving the health and well-being of individuals. You will work closely with patients, families, and healthcare providers to deliver high-quality, patient-centered care that addresses the physical, emotional, and social needs of our clients. This position will assist in connecting individuals with health and community support services, playing a crucial role in helping people access the care and resources they need directly. The role involves providing CHW or ECM Services on the spot and conducting outbound calls to connect clients to resources.

Responsibilities:

CHW/ ECM

Services:

1. Conduct patient assessments to identify health and social needs. 2. Develop personalized care plans in collaboration with patients, families, and healthcare providers. 3. Provide education and support on chronic disease management, healthy behaviors, and self-care. 4. Facilitate access to community resources, services, and referrals. 5. Coordinate care transitions and communicate with healthcare providers. 6. Conduct regular home visits and phone follow-ups to monitor progress and ensure ongoing support. 7. Document patient interactions and care plans in the electronic health record within 24 hours, and close all encounters. 8. Collaborate with interdisciplinary teams to address patient needs and improve health outcomes. 9. Identify and address social determinants of health and health disparities. 10. Provide cultural competency and linguistically appropriate services. 11. Maintain patient confidentiality and adhere to HIPAA guidelines. 12. CHW minimum productivity is expected to be 80% clinical (patient billable encounters) and 20% Non-productive (driving/documentation/outreach, etc.). 13. Schedule 75% of clients before the 15th of each month. 14. Conduct outreach for community awareness of the ECM program. 15. Attend regular staff meetings, training sessions, and other meetings as requested. 16. Minimum caseload of 25-30 ECM clients, and may increase during times when the clinic is experiencing a staffing shortage. 17. Minimum combined total of 20 CHW and ECM touches per month.

Community Outreach:

1. Initially, outbound calls will be made to individuals on the assigned referral lists to educate them regarding CHW and ECM services available to them under their health plan. a. Insurance must be verified before services can be provided to ensure the client is eligible. b. If the client's need is minimal and can be addressed in the short term, a CHW touch will be conducted on the spot, such as providing resources or navigating a website. c. If the client's need is extensive and requires a long-term plan to achieve their goals, an ECM intake/successful engagement will be conducted on the spot. 2. Engage members in a respectful, culturally sensitive, and trauma-informed manner. 3. Accurately document outreach activity using standardized tracking systems, designated outreach platforms, and Dr. Cloud. 4. Track member responses, time spent, and follow-up needs in accordance with approved program procedures. 5. Schedule intake appointments and ensure appropriate follow-up to confirm member engagement. 6. Follow internal workflows for outreach outcomes. 7. Confirm appointment attendance and relay updates to care and coordination teams as needed. 8. Identify and escalate issues such as insurance discrepancies, invalid contact information, urgent support needs, or language barriers. 9. Participate in regular team meetings, compliance training, and performance reviews.

NON-ESSENTIAL DUTIES AND RESPONSIBILITIES

Performs other duties as assigned. Ability to work independently and be self-directed and flexible. Ability to perform functions with minimal supervision. Ability to work at a high-volume level of accuracy.

Requirements:

1. A bachelor's degree in psychology, social work, human services, or a related field. 2. Community-based work, also known as in-vivo work, requires proper safety precautions. 3. Certification as a CHW (CCHW) or willingness to obtain within 18 months. 4. CPI and CPR within 30 days of hire. 5. Strong communication, interpersonal, and cultural competency skills. 6. Ability to work independently and as part of a team. 7. Basic computer skills and familiarity with electronic health records. 8. Valid driver's license and reliable transportation (if applicable).

Preferred Qualifications:

1. Certified as a CHW (CCHW) 2. Experience working with diverse populations and communities. 3. Knowledge of community resources and services. 4. Familiarity with care management software and technology. 5. Bilingual or multilingual skills.

Working Conditions:

1. Office and Community setting with frequent travel to client homes, community organizations, and healthcare providers. 2. Flexible scheduling to accommodate client needs, including evenings and weekends.

We Offer:

1. Competitive salary and benefits package. 2. Opportunities for professional growth and development. 3. Collaborative and supportive work environment. 4. The chance to make a meaningful difference in the lives of our patients and community

Job Types:

Full-time, Part-time Pay:

$24.00 - $28.00 per hour

Benefits:

401(k) Dental insurance Health insurance Paid time off Vision insurance People with a criminal record are encouraged to apply

Work Location:

Hybrid remote in Santa Rosa, CA 95401