Program Coordinator

POSITION TITLE: Program Coordinator-Care Management/ Master’s Level (MSW required)

PROGRAM: Pathways to Wellness

FSLA STATUS: Non-Exempt

REPORTS TO: Program Manager

LOCATION: Onsite

WAGE: $37 hour, 32/38 hours per week (70 hrs/pay period)

The Care Coordinator facilitates service coordination to a caseload of 50 participants who rely on the Emergency Room for non-emergency/routine medical care. The Pathways to Wellness program is grounded in the Social Determinants of Health and the Care Coordinator works closely with participants to identify and address social, emotional, and economic factors which contribute to over-utilization of the Emergency Department for routine care and may create barriers to overall wellness. The Care Coordinator will work with internal and external stakeholders to address the social determinants of health for participants. Referred participants may also include those experiencing chronic, diet-related health conditions (such as diabetes, hypertension, obesity, etc.) that are untreated or poorly managed. Services include 1:1 coaching, resource navigation, and development of individual success plans. The Care Coordinator utilizes best practices for coaching support, goal planning, and linking to resources. The Care Coordinator monitors participant’s progress on individual goals and objectives. Goals include the achievement of optimal health, access to services, advocacy, appropriate utilization of resources and collaboration with care providers to ensure participants needs are met in the community. This program does not provide medical advice or diagnosis – the objective is to be an accountability partner in achieving lifestyle changes that support the management of their conditions.

1.Conducts outreach to and serves as liaison to hospital partner in receiving referrals of participants who over-utilize the emergency department (ED) to gain understanding of the individual’s situation and needs.

2.Provides ongoing case management to a rolling caseload of 50 participants, interviews and evaluates referred and enrolled participants identify social, emotional and economic barriers, provides formal and informal coaching and guidance and co-creates Individual Success Plan (ISP) with participants to reach their individual goals.

3.Maintains and regularly updates Individual Success Plan (ISP) in collaboration with enrolled participants, monitoring improvements (e.g., reduction in utilization of the (ED), improved biometrics, etc.), and generating progress reports as needed.

4.Develops a trusting and open relationship with enrolled participants and assists with decision-making and referrals in relation to wellness and addressing key social determinants of health.

5.Assist participants with accessing community resources and services to increase stability (e.g. linkage to primary care physicians, health insurance, food banks, housing).

6.Collaborates with Pathways to Wellness team to ensure high-quality services and achievement of agency and funder goals for program completion.

7.Leverages readily available public resources through LA City & County and U.S. Department of Public Health.

8.Maintains accurate, well-written/well-documented case notes, and progress reports; conducts quarterly case file reviews to ensure conformance to program expectations and participant records are complete.

9.Works in close coordination with the relevant MEND staff to ensure program completion and goals are met while ensuring a positive experience for each participant.

10.Builds robust collaborations with other providers and community- and faith-based organizations that can support our participants wellness goals and address key Social Determinant of Health; stays aware of community resources to help meet participant needs.

11.Participates in department meetings, case conferences to support participant goals and program outcomes.

12.Other duties as assigned.

•Master of Social Work required, LCSW desirable.

•3 years’ experience in case management with a demonstrated track record of service coordination to achieve participant goals.

•Familiarity with healthcare systems (Hospitals Emergency Rooms, Urgent Care, Community Clinics)

•Full understanding of Social Determinants of Health and their impact on overall wellness.

•Strong Understanding of health equity and community health.

•Bilingual English/Spanish required.

•The successful candidate will be able to build strong relationships with community providers, clinics, and participants alike.

•Strong organizational and follow through skills, able to set and meet deadlines, adept at tracking data and program outcomes.

•Demonstrated ability to work effectively as a member of a team and work with people from a variety of backgrounds while maintaining confidentiality.

•Ability to express awareness of and sensitivity to culturally and economically diverse clients.

•Excellent communication and organizational skills; strong written and interpersonal skills.

•Valid CA Driver’s License and Current insurance; must have reliable transportation.

•Proficient in MS Office (Word, Excel, PowerPoint, Outlook); familiarity with Efforts to Outcomes (ETO) a plus; excellent internet & research skills.

•Must be able to remain in a stationary position 60-70 % of the time.

•May move, transport, boxes or program material weighing up to 25 lbs across the office for various needs.

•This position is a mandated reporter and also must have a satisfactory background check.