
Health and Social Services Coordinator - Field Based on Maui, HI
- Kahului, HI
- $23.41-41.83 per hour
- Permanent
- Full-time
- Engage with members face to face and telephonically
- Independently or as part of a care team, conduct comprehensive member assessments including evaluations of bio-psychosocial, functional, and behavioral health needs and evaluating for social risk factors
- Educate members on preventive health care measures and health and wellness information related to disease processes
- Educate member on appropriate utilization of services based on need (i.e. PCP vs ER)
- Work with members to develop healthcare goals and identify potential barriers to achieving those goals
- Assess, plan and implement care strategies that are individualized by member and directed toward the most appropriate, least restrictive level of care
- Connect member with relevant providers, programs and services
- Utilize motivational interviewing techniques to help member identify and understand their intrinsic goals and motivate members to engage in positive behavior change
- Communicate with all stakeholders and relay necessary health-related information to ensure quality coordinated care and services are provided expeditiously to all members
- Advocate for patients and families as needed to ensure the patient's needs and choices are fully represented and supported by the health care team
- Use technology to obtain and document health-related information
- Research member-related health information using internal and external systems (may include medical records systems, claims systems, health information exchange, benefit and eligibility platforms)
- Facilitate cross-systems supports for members accessing medical respite and other specialized community-based services and serve as the member's primary POC while engaged in those programs.
- Provide weekly follow-up with members in medical respite to identify and address member's health coordination needs as well as actively participate with the medical respite program to support discharge planning efforts
- Collaborate closely with the Housing Program Managers to offer updates on the medical respite members and providers to support program oversight
- Serve as the health coordination SME on pre-release supports, engaging with members pre/post release from incarceration to support community integration and promote positive health outcomes
- Collaborate closely with the Justice Systems Program Manager and other community partners in the identification, support and management of members incarcerated and requesting pre-release assistance; this position will require face-to-face interaction with members while incarcerated and after release into the community
- Conduct assessments and offer interventions tailored to the specific needs of members with justice involvement and engage additional health plan supports as needed
- High school education
- 3+ years of experience working in a member-facing role in a medical, community health or social services setting
- 1+ years of experience in at least one of the following service areas: mental health, behavioral health, addiction/substance abuse, crisis intervention, health education, homeless or homeless outreach services, managed care
- Familiar with community resources and social service programs
- Experience working with populations with complex medical, behavioral, social needs including incarcerated individuals
- Experience and confidence using electronic medical record systems, Outlook, Microsoft Teams, and Excel
- Current access or ability to obtain internet access via a landline
- Skill in developing trust and rapport with individuals who may be disengaged from the health care system
- Ability to locate and engage homeless members in a variety of community settings including homeless shelters, encampments, hygiene centers, transitional shelters, medical respite homes
- The ability to travel in assigned region to visit Medicaid members in their homes or in other community settings including hospitals, ERs, physician offices, and jail/prison up to 80% of the time
- College degree
- Background in managing populations with complex medical, behavioral and social needs
- Background in mental health or experience working with serious mental illness
- Case Management experience
- Experience with or familiarity with discharge planning
- Experience with electronic charting
- Experience with coordinating community resources