Care Coordinator

• This position requires travel within the San Fernando Valley*

Position: Lead Care Manager

Who we are:We are a non-profit health center led by an inclusive team dedicated to improving the health and well-being of the community. Founded in 1920, Eisner Health has grown to provide integrated, culturally competent, and affordable healthcare at multiple locations around the Los Angeles region. Our team works to provide trauma-informed services that address social and medical disparities in order to improve the health of communities and individuals across Los Angeles County.

Position Summary:The Lead Care Manager serves as the primary contact to patients in the Care Transformation Program and plays a central role in connecting the care team members with the patient and with each other for optimal communication about the patient’s Care Plan. The ultimate goal of the program is to effectively manage the patients over the continuum of care to ensure that their medical and psychosocial needs are met for a well-managed health condition and to minimize the likelihood of preventable hospital and emergency department utilization.

Duties and Responsibilities:Engages patients and offers and/or facilitates care management services where the patient lives, seeks care, or finds most easily accessible.Conducts comprehensive risk assessments and develops patient-centered Care Plans that includes goals based on the patients’ physical and psychosocial health needs and considers their personal preferences.Oversees effective implementation of Care Plan, ensuring initial plan is drafted with 60 days from the patient’s enrollment and that it is updated as necessary, but no less than one per quarter, thereafter.Educates patients on self-management skills and/or recruits support from a caregiver/family member to support the accomplishment of the Care Plan.Supports health behavior change utilizing motivational interviewing and trauma informed care practices.Monitors treatment adherence.Regularly initiates or participates in case conferences with clinical providers.Connects patient to social services, including housing, transportation, etc., as needed to achieve patient’s goals and well-managed care.Coordinates with hospital staff on discharge plan and with other transitional care as feasible.Accompanies patient to office visits, as needed and according to health plan guidelines.Maintains a regular contact schedule with enrolled patients that includes at least one in-person encounter per month.Document care management encounters in the Electronic Health Record (EHR) with the appropriate billing codes and internal tracking logs.Perform other duties as assigned.

Qualifications:Bachelor’s degree required in a related field, Masters preferred.Two years of experience in community health or social service setting requiredOne year of case management / care coordination experience required.English and Spanish fluency requiredProficiency in Microsoft Office Suite productsValid driver’s license and willing to drive to Eisner sites and communities where ECM patients liveMust be able to work in interdisciplinary team settingEffective communication and interpersonal skillsExperience with Electronic Health Records preferredAbility to independently seek out resources and work collaboratively

Benefits:Generous Paid Time Off benefit (23 days accrued per year).9 Paid Holidays.Medical insurance, PPO & zero deductible HMO options available.Low-cost dental & vision insurance.Opportunity for professional leadership training.Opportunities for loan repayment.403b plan with employer contribution at 3%.License renewal and professional membership reimbursement.Employer-Sponsored life insurance & long-term disability.