About the job
PneumaCare Health and Wellness is committed to uplifting the most vulnerable members of our community by enhancing stability and resilience in Community Supports, Enhanced Care Management, and Day Habilitation services. We work in collaboration with the Ministerial Association of Colusa County (MACC) and local churches to empower our communities through the Gospel.
As a Bilingual Community Care Coordinator under the direct supervision of the CalAIM Program Manager, you will play a pivotal role in coordinating and executing Enhanced Care Management (ECM) and Community Supports Management. Your responsibilities will include overseeing the delivery of ECM and CS services, and working collaboratively with members to identify and achieve their personal health care and psychosocial goals.
Key Responsibilities:
- Engage eligible members and provide services at locations that are accessible and convenient for them, adhering to health plan guidelines.
- Supervise the implementation of Care and/or Housing Plans.
- Connect with ECM members through phone or in-person interactions to facilitate engagement, assessments, follow-ups, and educational visits to develop and address Care and/or Housing Plans.
- Collaborate with members to identify their Plan goals and objectives.
- Link members to additional Community Supports and social services as needed.
- Accompany members to office visits as required, following health plan protocols.
- Coordinate transportation and facilitate care conference meetings, collaborating with resource partners to ensure accurate Plan updates.
- Utilize case documentation systems and electronic tracking systems to manage services and report data effectively.
- Attend and lead required training sessions for clinical and administrative staff.
- Partner with the Program Director to ensure ECM templates are effective in capturing necessary data.
- Review and develop protocols and policies in line with MACC requirements.
- Assist in generating required ECM and internal reports.
- Act as an advocate for members in interactions with healthcare professionals, employing motivational interviewing, trauma-informed care, and harm-reduction strategies.
- Coordinate with hospital staff on discharge plans.