Health Home Care Coordinator

                                                                        JOB DESCRIPTION


  • Shafter

Job Summary: This position is responsible for assigned social work case management functions for Omni Family Health (OFH). The primary duty of the Health Home Care Coordinator is to identify and assist members that are displaying a complex variety of social and/or emotional needs and usage of services reflective of abuse, lack of compliance to medical or pharmaceutical instructions, or self-destructive habits. The care coordinator coordinates with these members and the member’s primary care provider in an effort to provide better medical management and to track and gauge the effectiveness of that effort.

The Health Home Care Coordinator will work closely with a multi-disciplinary team in the health home model, outpatient case management and primary care to develop and provide clinical services that are necessary to achieve an extended healthcare focus beyond the inpatient setting or traditional primary care of specialist office visits. The Health Home Care Coordinator will plan and implement medical social service delivery programs, promote coordination, continuity of care, and quality management in support of Health Home members/patients. This position serves as a liaison to all Health Home staff, providers, and members to provide services.

Job Duties:     

  1. Engage with members in the Health Home Project (HHP).
  2. Monitor treatment adherence.
  3. Provide health promotion and self-management training.
  4. Make frequent calls to the HHP members.
  5. Establishes and maintains interpersonal relationships with both internal and external staff and other agencies.
  6. Assists members and/or families/significant others, regarding discharge issues.
  7. Provides case management in conjunction with other case management staff and community providers in emergency and non-emergency situations.
  8. Documents interactions with members and providers as required and maintains records of referral interactions with behavioral health.
  9. Has the ability to independently assess the psychosocial functioning needs of patients and their family members and to formulate and implement a treatment plan, identifying the patient’s problems, strengths, weaknesses, coping skills and assistance needed, in collaboration with the patient, family and interdisciplinary treatment team.
  10. Other duties related to HHP as assigned.
  11. Home visits if indicated.

 Job Requirements:    

  1. Excellent written, verbal and interpersonal communication skills.
  2. Have strong leadership with ability to integrate multi-disciplinary teams.
  3. Ability to demonstrate knowledge and experience of complex systems of care.
  4. Ability to work under pressure.
  5. Ability and willingness to treat all patients with the utmost kindness and consideration in the most trying situations.
  6. Friendly personality with the desire to work with the public.
  7. Ability to handle multi-functions.
  8. Understanding of community based organizations.
  9. Promotes and believes in OFH mission statement.
  10. Ability to relate to the public regardless of ethnic, religious and economic status.
  11. Must be willing to work at any Omni Family Health, location, other that the assigned site and be agreeable to work weekends, if so needed.
  12. Must obtain a Valid California Drivers License at all times plus proof of insurance, to allow you to be placed in all Omni Family Health clinics if needed.
  13. Must have active Basic Life Support Certification from the American Heart Association.
  14. Commitment to the concepts of preventive health care program and team approach to health care delivery.

 Additional Duties:

  1. HIPPA compliance – Responsible for maintaining abreast of and in compliance with all HIPPA regulations and requirements. Treats all member information confidential.
  2. Compliance – Ensure compliance with all local, state and federal regulations.
  3. QA/QI – Participate in QA/QI activities and contribute towards the overall performance improvement of the organization.
  4. IT – Required to learn and use the Electronic Health Record and its components. As required by the job functions and highlighted in the Policies and Procedures. These components include NextGen, and other electronic features, as they are developed and implemented, as applicable to work environment.
  5. All employees will participate in Patient Centered Health Home Model at Omni Family Health.

 Qualifications, Education, and Experience:

  1. Must be a graduate of an accredited school of nursing, with a current California LVN license or a Certified Medical Assistant.
  2. Two years in care coordination service delivery.
  3. Previous patient centered medical home and NCQA knowledge a plus.
  4. Bilingual in English/Spanish preferred


Responsible To:          Health Home Project Manager

Classification:             Full or Part Time Position, Non-exempt