Care Coordinator

Overview

Life Long Medical Care has an exciting opportunity for a Care Coordinator at our Family Medical Residency Program in Richmond, California. The Care Coordinator will provide short term resource coordination and occasional longer term case management to patients in a busy primary care clinic serving a diverse and vulnerable population.

This is a full time, benefit eligible position. Bilingual English/Spanish a must.

This position is represented by SEIU-UHW. Salaries and benefits are set by a collective bargaining agreement (CBA), and an employee in this position must remain a member in good standing of SEIU-UHW, as defined in the CBA.

Life Long Medical Care is a large, multi-site, Federally Qualified Health Center (FQHC) with a rich history of providing innovative healthcare and social services to a wonderfully diverse patient community. Our patient-centered health home is a dynamic place to work, practice, and grow. We have over 15 primary care health centers and deliver integrated services including psychosocial, referrals, chronic disease management, dental, health education, home visits, and much, much more.

Benefits

Compensation: $22 - $23/hour. We offer excellent benefits including: medical, dental, vision (including dependent and domestic partner coverage), generous leave benefits including nine paid holidays, Flexible Spending Accounts, 403(b) retirement savings plan.

Clinical:
Direct Service

• Assesses patients’ psychosocial needs, assists in developing a patient-centered plan of care, and arranges for service delivery as needed. Meets with clients in clinic or community as safe and appropriate. Documents visits appropriately in EHR.
• Develops relationships with community agencies and service providers and links clients to these services as needed. Coordinates with behavioral health team to act as an advocate for the client and liaison with outside agencies.
• Assist and support patients in following through with medical care plans (e.g., attending specialist visits, obtaining labs or imaging, etc.) Communicate with providers and RN (Registered Nurse) team regarding outcomes.
  • Provides care coordination services, including referrals to community resources, advocacy for school-based interventions (IEP, 504 Plans, school-based counseling), coordination with medical and mental health providers, troubleshooting around insurance, medication, or transportation issues. Areas of assistance include Legal aid Paratransit and other Transportation programs Applications for financial benefits (SSI, SDI, GA, etc.)
  • Supportive housing services (Section-8, HUD (Housing and Urban Development), etc.)
  • Perform ongoing assessment of food insecurity and link patients to Jenkins-based and community-based resources for nutrition support (meals on wheels, WIC (Women with Infants and Children), Wellness Center, etc.).
  • In consultation with medical providers, provide ongoing assessments of in-home support (IHSS (InHome Supportive Services), Home Health, etc.).
  • Patient medication compliance and need for additional support (i.e., bubble packs).
  • Support medical team and families with discussions around end-of-life care and documentation (DNR/DNI, POLST, etc.)
• Provides some clinical case management to individual clients.
• Refers patients to eligibility team for assistance with insurance and other entitlement programs (Medi-Cal, Contra Costa CARES, Cal Fresh, etc.)

Clinical:
Team Participation

• Participates constructively in both behavioral health team and interdisciplinary team to address the clinical and psychosocial needs of individual clients.
• Be available for in-person warm-hand-offs for on-site consultation with patients.
• Attends staff clinical team meetings.
• Collaborates professionally with interdisciplinary team members and partners including other Behavioral Health providers, Patient Advocates, Primary Care Providers, Community Health Workers, Medical Assistants, and office support staff.
• Advances the integration of Behavioral Health and Medical approaches to patient care through constructive and respectful partnerships.
• Participates in agency and/or grant driven directives and outcomes.

• Patient-Centere…