Job description

ORGANIZATION
The mission of Ravenswood Family Health Network (RFHN) is to improve the health of the community by providing culturally sensitive, integrated primary and preventative health care to all, regardless of ability to pay or immigration status, and collaborating with community partners to address the social determinants of health.
Position Summary
Under the direction of the Social Services Manager, Nurse Supervisor, and the Integrated Behavioral Health Services Director, the Social Services Care Coordinator will provide a wide range of case management services for RFHN patients, including those participating in the following programs: Enhanced Care Management (ECM), Medication- Assisted Treatment (MAT), and Health Care for the Homeless (HCH). The Patient Navigator is a key staff member in the development of collaborative treatment care management plans for patients that support patients needs in the areas of physical health, mental health, substance abuse disorders, community-based long-term services support, social supports and the patients social determinants of health. The patient navigator is responsible for comprehensive case management assessments, care coordination, outreach and engagement, identification of patient support needs, referrals to community social supports, and fostering patients autonomy and independent skills.
Duties and Responsibilities
To be performed in accordance with RFHN Policies and Procedures

• Receives training to be qualified to provide services to RFHN patients according to program guidelines that meet the requirements of ECM, MAT, and HCH.
• Conducts patient outreach and engagement, including; community and street-level outreach.
• Conducts comprehensive Intake assessment.
• Maintains compliance with all applicable county, state and federal laws and regulations, funder and program requirements including maintaining timely accurate documentation in EPIC and Health Plan Electronic systems.
• Carries a caseload of 50-60 active cases.
• Conducts outreach within 30 days after receiving member outreach information.
• Develops a Care Management Plan that incorporates patients needs in the areas of physical health, mental health, SUD, community-based Long-Term Services Support, oral health, palliative care, social supports, and Social Determinants of Health.
• Supports patient engagement in treatment including scheduling appointments, appointment reminders, coordinating transportation, accompanies patient to critical appointments, identifies and addresses other barriers to patients engagement in treatment.
• Ensures regular contact with the patient and their family member(s), guardian, caregiver, and/or authorized support person(s) as part of care coordination.
• Engages and helps patient to participate in and manage their care.
• Supports/encourages patients in strengthening their skills to identify and access resources to assist them in managing and prevention of chronic conditions.
• Provides transitional care for patients during discharge from a hospital and coordination of care to provide adherence support and referrals to appropriate resources and community supports, as needed.
• Assists patients in accessing additional benefits and related documentation such as, Social Security Insurance (SSI), CalFresh, cash aid, and obtaining required documentation to apply (ID, birth certificate, immigration status, financial records, marriage/divorce records, proof of medical conditions, etc.
• Maintains up to date adequate documentation necessary for the collection of data and statistics pertaining to program outcomes, demographics, and information as required by funders.
• Consults with medical and mental health providers and participates in case conferences to assess the patients mental and physical status and health.
• Establishes program policies, procedures and standard work guidelines.
• Attends, participates and reports status of program activities during 1:1 meeting with supervisor and other meetings as requested by supervisor.
• Brings urgent/critical issues to supervisors attention with a sense of urgency.
• Performs other related duties as assigned by supervisor.

QUALIFICATIONS

• Completion of COVID-19 vaccine series and booster required.
• High School diploma or GED certificate required; Associate degree (AA) and/or Bachelors degree preferred.
• One-year experience working in a healthcare or social service setting providing mental health, Enhanced Care Management, Health Care for the Homeless and/or Medication-Assisted Treatment outreach services.
• Excellent interpersonal, oral and written communication skills.
• Strong organizational, problem-solving and analytical skills; able to manage competing priorities and workflow.
• Proactive approach to daily tasks.
• Proficient in data entry and computer software; Experience with Epic software a plus.
• Bilingual, proficient in Spanish required.
• Possession of a California Drivers License with a Clean Record.
• Possession of a personal registered automobile with current insurance operating in good condition.
• Ability to travel to all clinic locations, patients residence and/or other community setting to meet patient.
• Ability to work flexible hours that may include evenings and occasional weekends.
• Basic Life Support (BLS) certificate.

Pay rate is commensurate with experience.
Ravenswood Family Health Network is an equal opportunity employer.

Job Type: Full-time

Pay: $25.00 - $40.00 per hour

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