Community Outreach Care Coordinator



Support and promote LACHC’s mission to follow Christ by loving and serving our neighbors
through comprehensive, quality healthcare. The Community Outreach Care Coordinator (CO-
CC) will manage a caseload of clinic patients to coordinate the full range of physical health,
behavioral health, community-based services, including long-term services and supports. The
CO-CC is accountable for assessing clients’ needs, coordinating with indicated entities in order
to facilitate authorization as required, and access to identified needed services as necessary to
support the achievement of individualized health action goals. The CO-CC is a non-clinical team
members skilled at engaging with patients over the phone and in-person. In addition to
individual care coordination, the CO-CC engages in initiatives designed to promote the
organization and its services to the community and promote new patient outreach and




Community Outreach

  • Clear understanding of nonprofit and community resources landscape.
  • Assess, organize, and initiate partnership activities to enhance Care
  • Coordination services provided to current and potential patients.
  • Represent the organization at community and faith-based events and activities.
  • Attend community meetings, such as coalition and advocacy meetings,
    community updates, case conferencing, etc.
  • Distribute informational material to patients and community partners to describe
    programs and services.
  • Build and maintain positive working relationships with community partners.
  • Conduct street outreach on a weekly basis.
  • Employ strategic planning to engage potential patients and link to clinic services
    with the goal of 20 linkages per week.
  • Use effective communication skills such as active and reflective listening to build
    rapport with vulnerable and difficult-to-engage clients.
  • Use evidenced based outreach strategies to locate clients and link them to care.
  • Document each outreach contact during or after each outreach event.
  • Motivate patients to be active and engaged participants in their health.
  • Assist patients with scheduling appointments and assisting with completion of
    registration paperwork for patient care.
  • Supply or obtain necessary items, such as hygiene kits, clothing, blankets, etc.
  • Assess supply needs for patient population and strategize resolution.
  • Organize, promote, and track in-kind donation initiatives for Care Coordination.
  • Utilize all resource directories needed including 211, Aunt Bertha, SPA 4
    resource sheets, and LACHC-specific resource guide.
  • Utilize, maintain, and update LACHC resource guide as changes occur and keep
    resource information on-hand to give to clients for all applicable resources.
  • Conduct outreach and enrollment calls to eligible patients for the Health Homes
    Program with a goal of 50 contacts per week.
  • Ability to work in groups as well as self-guided, independent Care Coordination.
  • Demonstrable experience and understanding of coalition building and nonprofit advocacy, engagement with relevant initiatives, and briefings to Care Coordination Director and Department.

Patient Assessment and Care Planning

  • Maintain a patient caseload consisting of general Care Coordination and Health
    Homes Program participants.
  • Provide immediate assistance to patients as needed, including locating
    emergency shelter, food resources, etc., based on internal on-call Care
    Coordination schedule.
  • Apply critical thinking skills and sound decision-making capabilities, often under
    pressure, in complex situations as needed.
  • Interview and assess clients to identify biological, psychological, social, and
    economic factors which may interfere with attaining stability and optimum health.
  • Assess each client’s stage of change and readiness for self-management.
  • Collaborate with patients to develop comprehensive, individualized, and person-
    centered care plans that are based on the needs and desires of each client.
  • Monitor status and completion of care plan objectives, reassess as needed.
  • Enter all appropriate data into the Homeless Management Information System
    (HMIS), following the criteria set out by HUD for data elements and the workflows
    set by the Los Angeles Homeless Services Authority (LAHSA).
  • Document all evaluations, care plans, interventions, and referrals performed per
    established EHR, Care Coordination, and Health Homes Program processes.
  • Expertise in administering structured assessments, including assessments on
    Social Determinants of Health, to gather, track, and assess client progress.
  • Demonstrable expertise in condition(s), and evidence-based strategies to
    address condition(s), common in the patient population, including: Domestic
    Violence, Substance Use, Mental and/or Physical Health Condition(s), Re-Entry,
    Chronic Homelessness, etc.

Care Coordination: 

  • Apply evidence-based interventions, such as motivational interviewing and harm
    reduction, to decrease or prevent complications and optimize patient well-being.
  • Promote self-management skills for each client to achieve self-directed,
    individualized health goals that promote recovery, improved functional and/or
    health status, and/or prevent or slow declines in functioning.
  • Ensure each client is knowledgeable about their condition(s), by providing
    culturally appropriate information that meets health literacy standards, in order to
    encourage and promote their adherence to treatment.
  • Provide health education on appropriate and condition-related topics, such as
    nutrition, disease management, and treatment compliance.
  • Engage in care coordination activities as indicated, which may include:
  • Monitor and encourage treatment plan adherence.
  • Manage referrals, coordination, and follow-up for services and supports.
  • Ensure appropriate care at level of care transitions by providing evidence-
    based transition planning.
  • Assisting clients with linkage and access to vital and appropriate
    resources per eligibility status, such as:
  • Housing;
  • Substance abuse treatment;
  • Mental health care; and
  • Public benefits.
  • Provide assistance with documentation and identification needs
  • Assist clients with locating and obtaining transportation to/from appropriate medical and/or social service appointments
  • Conduct suicidality assessments and engage subsequent workflow to provide
    emergency assistance to patients based on mental health status and risk.
  • Apply Harm Reduction strategies to engage with residents, including participation
    and certification is Narcan training.
  • Provide accompaniment services to clients as needed, determined by patient
    assessment and interviews.
  • Utilize strengths-based, solution-focused strategies to assist patients.
  • Create SMART goals in collaboration with patients.

Continuity of Care

  • Participate in case conferences as needed.
  • Create health education courses and to bolster training materials for the
  • Ensure all identified biopsychosocial needs are addressed with care coordination
    and medical treatment planning.
  • Ensure each client’s care is continuous and integrated among all service
  • Communicate with internal department and/or outside care agencies as well as
    IPA/health plans, as applicable, to initiate referrals and ensure appointment
  • Utilize and improve internal tracking systems to accurately capture Care
    Coordination progress within assigned roster.
  • Synthesize complex information obtained from assessments, trainings, and
    research to implement up-to-date, evidence-based interventions for impactful
    Care Coordination.
  • Participate and obtain certification in LA Care’s training academy for Care
    Coordination practices.
  • Participate and obtain certification in ongoing training topics as assigned,
    including, but not limited to: Motivational Interviewing, De-Escalation Strategies,
    Fair Housing, Trauma-Informed Care, Safety Planning, Accompaniment, Case
    Management Core Functions.
  • Accompany identified clients to critical appointments.
  • Engage in resource outreach and engagement and inform Care Coordination
    Department of new referral services.


  • Other Duties as Assigned




To perform this job successfully, an individual must be able to perform each essential
duty satisfactorily. The requirements listed below are representative of the knowledge,
skill, and/or ability required. Reasonable accommodations may be made to enable
individuals with disabilities to perform the essential functions.

  •  CPR Certification required.
  • Bi-lingual Spanish preferred




Bachelor’s degree in social work or related field from a four-year college or university is
required. Two years of case management experience is preferred. Prior experience
working with individuals experiencing homeless, substance use, physical health
conditions, mental health conditions.




Experience with Electronic Health Records, Microsoft Word, Microsoft Access, and
Microsoft Excel is preferred. Experience with HMIS and CHAMP databases preferred.




Familiarity with medical terms and operations of clinics is useful.
Proficiency in English required, Bi-lingual/ Bi-literal Spanish is preferred.




Ability to calculate figures and amounts such as totals, proportions and percentages.




Ability to solve practical problems and deal with a variety of concrete variables in situations
where only limited standardization exists. Ability to interpret a variety of instructions furnished in
written, oral, diagram, or schedule form. Ability to independently make decisions in high-
pressure situations.
Regular, Full-time, Non-Exempt position.  Healthcare Benefits including 403B
Retirement Plan with employer match.  Annual salary range is $43,148 – $64,722.
Equal Opportunity Employer.  We are willing to consider candidates with criminal
histories.  Please submit resumes to

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