Patient Care Coordinator

• Interview members to assess medical and social determinant of healthcare gaps and provide education about their condition and medication, while developing individualized care plans.
• Respond to member inquiries and concerns, ensuring adherence to hospital and legal requirements.
• Collaborate with interdisciplinary teams, locate medical and social resources, and coordinate social service plans.
• Maintain on-going contact with members, via telehealth and in-person visitation.
• Advocate for members, consult with healthcare providers, arrange appointments and treatment plans, evaluate member progress, and assist with healthcare barriers.
• Maintain empathy and professionalism while contacting members and families.
• Supporting behavioral health coordination, Substance Abuse and Community Resources.
• Perform additional duties as assigned.

• Individuals experiencing homelessness: Lacking a fixed, regular, and adequate nighttime residence.
• Individuals at risk for avoidable hospital or emergency department utilization: Five or more emergency room visits in a six-month period that could have been avoided with appropriate outpatient care or improved treatment adherence.
• Individuals with Serious Mental Health and/ or substance use disorder needs: Adults who meet the eligibility criteria for participation in, or obtaining services through Specialist mental health services or the Drug Medi-Cal organized delivery system or Drug Medi-Cal program.
• Individuals transitioning from incarceration/Justice Involved: Adults transitioning from a correctional setting or transitioned from a correction setting within the past 12 months, or children and youth who are transitioning from a youth correctional facility or transitioned from being in a youth correctional facility within the past 12 months.
• Adults living in the community and at risk for long-term care institutionalization: Adults who are living in the community who meet the SNF Level of Care criteria; or who require lower-acuity skilled nursing or equipment for prevention, diagnosis, or treatment of acute illness or injury.
• Adult nursing facility residents transitioning to the community: Adult nursing residents who are interested in moving out of the institution, and are likely candidates to do so successfully, and are able to reside continuously in the community.
• Children and youth enrolled in California Children's Services (CCS) or CCS Whole Child Model (WCM) with Additional Needs Beyond the CCS condition: Children and youth enrolled in CCS or CCS WCM and are experiencing at least one complex social factor influencing their health.
• Children and Youth Involved in Child Welfare
• Individuals with Intellectual/ Developmental Disabilities: Adults who have a diagnosed I/ DD and qualify for eligibility in any other adult ECM population of focus.
• Pregnant and Postpartum individuals; Birth Equity Population of Focus: Adults and youth who are pregnant or postpartum and qualify for eligibility in any other adult or youth ECM POF, or are subject to racial and ethnic disparities.

• High school diploma or GED required.
• Minimum of 1 year experience in case management, member care, customer service, call center, or member care required.
• Valid California driver's license and valid vehicle insurance required.
• MA certificate or medical terminology knowledge preferred.

• Excellent communication, interpersonal, customer service and organizational skills.
• Computer skills for documentation, email and chat support.
• Proficient skills in working independently and collaboratively in a team to provide member care.
• Proficiency in multitasking, organization, and attention to detail is required for effectively providing care to multiple members simultaneously.
• Candidates should exhibit the capability to utilize resources effectively for problem-solving while maintaining composure under pressure in a compassionate manner.
• Applicants must demonstrate proficient speaking, reading, and typing abilities and possess strong proofreading skills.

• Must be able to travel using personal vehicle to complete outreach visits. Mileage reimbursement for the use of your vehicle is at a standard rate.
• Prolonged periods of sitting at an office desk on the computer.
• Lifting: Able to lift up to 15lbs.

• First week of employment will report to the Sacramento office.
• Mileage reimbursement is offered at 70 cents per mile.
• Commute to the Sacramento office is considered work time. Staff member can leave their home at 8:30am.
• First month is weekly visits on Wednesdays to the Sacramento office
• After the first month the staff member will be evaluated on the frequencies of office visits.
• Office visits will decrease to once per month based on the needs of the office.

Serene Health