Marin Community Clinics

  • Complex Care Navigator, Whole Person Care and IOPCM (Bilingual)

    Type
    Regular Full-Time
    Types
    Regular Full Time
    Location
    US-CA-Novato
    Category
    Care Navigation/Social Work
  • Overview

    Under the supervision of on-site Medical Director, the Complex Care Navigator provides case management to high-risk, complex patients to maintain and improve patients’ functional status, increase their capacity to self-manage their condition, and reduce their need for acute care services. Additionally, the Complex Care Navigator provides assistance to high risk, complex patients with a variety of programs, public benefits, and services.

    Responsibilities

    • Assist RN Care Coordinator in developing MCC’s care coordination programs, which includes Whole Person Care Program (WPC) and Intensive Outpatient Case Management Program (IOPCM)
    • Work with RN Care Coordinator and to ensure that deliverables are met for MCC’s care coordination programs
    • Actively identify and enroll patients for care coordination based on eligibility criteria
    • Participate in Care Team meetings to include daily huddles, monthly care team meetings, complex care case conferences and other related meetingsFacilitate care transitions from ER or Hospital to SNF or home.
    • Assist RN Care Coordinator with regular client follow-up and maintain contact with clients as needed to assure completion of care plan, and provide regular feedback to primary provider of care and staff regarding clients' progress.
    • Works with the Certified Enrollment Counselors to identify patients who need enrollment support. Prepares patients for in-person interviews that take place at the Public Assistance Department. Accompanies patients to their in-person interviews and provides them with support throughout the interview.
    • Works closely with the Outreach and Enrollment team and outside stakeholders to understand how policy changes impact health insurance eligibility. Provides assistance and support to individuals and families during transition periods or during changes in financial or legal status.
    • Works with the Referral Coordinators to identify uninsured patients who are in need of specialty care and need to apply for charity care at hospitals or other healthcare facilities. Assists patients to fill out the charity care applications and provides any follow-up needed.
    • Provides culturally and linguistically appropriate health insurance and social service enrollment/application assistance for demographically diverse patient populations.
    • Ensures that patients access services available in the community based on the detailed knowledge of the relevant access arrangements, eligibility criteria and available services.
    • Assists with timely scheduling of appointments (e.g., healthcare, social services, etc.) for patients to address problems/barriers addressing basic needs, social determinants of health and other economic factors. Provides advocacy, support in negotiating/coordinating with service agencies/organizations. May attend appointments with patients.
    • Maintains good working relationships with community partners by working as a liaison with other agencies and the community; participates in local community forums. Actively builds partnerships and strengthens existing collaborations.
    • Enables the impact of the service to be assessed and to inform the improvement of other local services by keeping electronic records of all contracts, enrollments, referrals and interventions, and producing regular reports on activity and outcomes.
    • Provides services in appropriate internal and external community forums (e.g., weekly Health Hubs, schools, partnering agencies etc.).
    • Creates educational materials such as flyers and brochures with helpful resources for patients.
    • Assists Health Hubs Coordinator, as needed, with the weekly Health Hubs. Participates in bi-monthly “Community Resource Table” at Health Hubs.
    • Provides clerical support such as data entry, calling resources, making copies, filing, as needed.
    • Leads trainings, workshops, groups and clinics on policy changes, community resources, government benefits, and appropriate supports for patients and MCC staff members.
    • Oversees and manages departmental volunteers, interns, and supports CARE Team with clinic-level resource management.
    • Assists with projects and grants that address the “social determinants of health.”
    • Other duties as assigned by supervisor.

     

     

    Qualifications

                                                                                             

    • Requires graduation from college and the possession of a Bachelor’s degree in Social Services/Work or related field, and 2 years of experience in a community-based organization setting (e.g., health center, etc.)
    • Knowledge of Electronic Health Records and Electronic Practice Management Systems preferred.
    • Basic knowledge of Microsoft Office software required: Outlook E-mail, Word, PowerPoint and Excel.
    • Training and Certifications (to be completed within 12 months of employment):       Covered California Enrollment Counselor certification; Patient/Health Navigation training and certification (funded by MCC).
    • Project coordination experience preferred; ability to meet deadlines and manage changing priorities
    • Ability to drive to the various MCC clinic sites (Larkspur, Novato, San Rafael) as needed
    • Ability to attend off-site care coordination trainings (can include but is not limited to travel in North Bay such as Petaluma and Santa Rosa.
    • Ability to problem-solve and have acute attention to detail
    • Ability to work independently and exercise good judgment with appropriate supervision.
    • Ability to maintain strict confidentiality regarding patient information.
    • Ability to understand complex concepts and convey them in a manner that is easily understood by layperson.
    • Ability to manage and prioritize communications from multiple staff, organizations, patients, etc., at the same time.
    • Ability to organize and review large amounts of data in an organized and efficient manner.

     

     

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