Plans, organizes and directs all aspects of the care coordination department to ensure necessary care coordination services are provided to patients and their families. Has overall responsibility for the management and operations of the Health Homes Program (HHP) and ensuring that HHP members receive access to HHP services. Directs and supervises the department staff, including Care Coordinators. Develops and implements programs, policies and procedures pertaining to the delivery of care coordination services to patients and their families based on research of evidenced based practices and successful models of care. Implements systems and workflows that ensure high quality delivery of evidenced based practices. Evaluates the effectiveness of all programs, policies, and procedures. Oversees and directs the development of care coordination training within the care coordination department.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following:
- Plans, organizes and directs all aspects of the care coordination department to ensure necessary care coordination services are provided to patients and their families.
- Directs and supervises the department staff, including the Care Coordinators.
- Prepares performance evaluations of direct subordinate staff.
- Interviews, selects, and works with Human Resources to hire Care Coordinators as needed.
- Develops and implements programs, policies and procedures pertaining to the delivery of care coordination services to patients and their families based on research of evidenced based practices and successful models of care.
- Implements systems and workflows that ensure high quality delivery of evidenced based practices.
- Evaluates the effectiveness of all programs, policies, and procedures.
- Participates with various departments within the organization and professional staff of other disciplines in the formulation of programs, policies, and procedures to integrate and coordinate services.
- Reviews and informs Health Action Plans for clients receiving care coordination services.
- Has overall responsibility for the management and operations of the Health Homes Program.
- Has responsibility for quality measures and reporting for the HHP.
- Facilitates integration of care coordination with primary care and behavioral health departments.
- Oversees and directs the development of employee training within the care coordination department to increase professional knowledge and skills of staff.
- Ensures compliance with federal and state laws in the provision of care coordination services within the organization, ensures compliance with all contracts related to care coordination services, and ensures compliance with all LACHC policies and procedures.
- Ensures quality control and accountability in the care coordination services provided.
- Reviews/modifies policies and procedures related to care coordination services and those assigned by the Chief Medical Officer.
- Participates actively as a member of LACHC Leadership Team, providing input and assisting in the direction of the Clinic.
- Provides direct services to patients as needed.
- Develop social/emotional assessments and formulate care plans based on evaluation of the patient’s past, present, and future medical and socioeconomic functioning.
- Maintain active involvement in the Coordinated Entry System and ensure that care coordination patients needing permanent housing are entered into the system and provided with navigation through the housing process.
- Provides consultation services to a multi-disciplinary team within an integrated care model by evaluating the environmental and psychosocial implications of the patient’s illness when planning medical treatment.
- Documents all evaluations, care plans, interventions and referrals performed.
- Gathers and analyzes program data (including data for employee SMART goals), implements action plans that result in measurable outcomes, and ensures that all reporting requirements of the Health Homes Program are met.
- Builds and maintains relationships with other community organizations—such as housing providers, transportation providers, food pantries, and City and County agencies– to ensure that a robust, active resource guide is in use at all times.
- Actively participate at external meetings including Community Clinic Association of LA County (CCALAC) Homeless Health Advisory Group, CCALAC Advocacy Workgroup, LA Central Provider’s Collaborative, and others as appropriate.
Other duties may be 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.
Master’s Degree in Social Work, Public Health, or other related field from an accredited graduate school. Two years of social work experience preferred. One year of administrative experience required.
Minimum 2 years working with homeless, low income, mentally ill, substance addicted populations preferred. Minimum 1 year supervisory experience as director of a social services program preferred. Prior experience working within a community mental health or primary care, medical setting preferred.
Experience with Microsoft Windows and Microsoft Excel preferred.
Familiarity with medical terms and medical clinic operations is useful. Proficiency in English required. Bi-lingual and bi-literal in Spanish highly preferred,
Regular, Full-time, Exempt position. Medical, dental and Vision benefits. 403B retirement plan with employer match. Equal Opportunity Employer. We will consider candidates with criminal histories. Salary Range available upon request.