- Contact eligible Health Homes clients to conduct intake and set up in-person meetings
- Arrange mailed communications with clients who are unable to be contacted via telephone
- Meet with clients in the most easily accessible setting, within Neighborhood Networks guidelines
- Work with clients to perform a Health Risk Assessment and create a Health Action Plan
- Assist clients in scheduling appointments with providers; arranging transportation for healthcare visits; getting prescriptions filled; and following up with clients on missed appointments.
- Assists clients in accessing social services such as community-based resources for housing, food, employment, etc.
- Conducts ongoing or telephonic and/or in person outreach visits with clients as needed.
- Guides clients to maintain Medi-Cal (Medicaid) eligibility and other financial resources as appropriate.
- Conduct health promotion and self‐management training with clients
- Arrange transportation for clients, as needed
- Assist with linkage to social supports
- Distribute health promotion materials
- Connect clients to other social services and supports as needed
- Advocate on behalf of clients
- Work with medical facility/hospital staff to ensure smooth and well supported transitions
- Engage clients with motivational interviewing and trauma-informed care practices
- Monitor treatment adherence (including medication)
- Document all client outcomes using specified care management data platform
- Participate in weekly care conference calls
- Participate in learning collaborative meetings
- Participates in staff meetings, supervision, training and other required agency and community meetings.
- Complete English/Spanish written document translation as needed
- Adheres to all agency policies and procedures including HIPAA and crisis intervention
- Must be able to work cooperatively in multidisciplinary teams.
- Completes all other duties as assigned.
Required Education and Experience
Compensation and Benefits
Minimum of a Bachelors degree required Minimum of one year of experience working with individuals that have chronic health conditions, and or mental health challenges such as Care Managers, Case Managers or Care Coordinators. Must have experience living or working in the community to be served (North County San Diego), including awareness of available resources, community conditions, barriers, and assets.
Knowledge, Skills, and Abilities Required:
Bilingual Spanish is required including reading and writing. Knowledge of working in a health care setting. Possess excellent written and verbal communication skills and the ability to think and express oneself in a creative manner. Demonstrates the interpersonal sensitivity and cultural competency needed for working with diverse populations. Deliveries services through a client-focused approach. Establish and maintains effective working relationships while showing open mindedness and a collaborative spirit. Compatibility with agency purpose, goals, philosophy, and approach. Demonstrates enthusiasm and passion for their work. Utilizes a creative approach to problem solving. Interactions with others reflect a spirit of honesty, humbleness, and self-awareness. Accepts constructive criticism with a positive attitude and willingness to implement change. Ability to work well independently and demonstrate appropriate initiative. Must demonstrate knowledge of trauma Informed, client driven, and culturally competent care.
Reliable transportation. Must have a California driver license and good driving record. Willing to use own, properly insured, reliable vehicle for the job (mileage reimbursed). Employment subject to clearances, including background finger printing checks, driving record, tuberculosis testing, and drug testing.
Physical Demands/Work Environment
Your well-being matters at North County Lifeline!
- Paid vacation
- Paid sick time
- Paid holidays (13 days)
- Exceptional medical, dental, vision, chiropractic and acupuncture coverage
- Free health and wellness programs
- Free Life Insurance
- Employee Assistance program
- Great employee incentive award programs
- Training and education assistance
- Matched 403b retirement plan
- Flexible Spending Account
- Menu of optional benefits, including short term disability, critical illness, accident, hospitalization and cancer policy
Pay Range ($16.60 -$18.26) Salary will commensurate with experience and education. Differential pay offered for bilingual skills.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is frequently required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; taste or smell. The employee may occasionally lift and/or move up to 15 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus. The employee may be exposed in an extremely stressful environment where there are considerable mental and emotional demands. Travel is required to client homes. Employee may be exposed to weather conditions prevalent at the time. The employee will be required to operate office equipment requiring repetitive hand movement and fine coordination including use of a computer.
Non-exempt, Full-time, 40 hours a week- Monday – Friday- Flexible hours (may include evenings and weekends)