Care Coordinator - ECM - San Bernadino County

Amity Foundation, an internationally acclaimed Teaching, and Therapeutic Community is seeking compassionate and enthusiastic individuals with a desire to teach, learn and join our community as a Community Health Worker. This groundbreaking opportunity will allow you to work with our prison and re-entry programs helping the community and will also enhance your training and experience in the field.

About Amity:

Amity Foundation is a safe place where people can change in an environment that fosters trust; where new values can be formed; responsibility developed, and lasting relationships built. Amity is dedicated to the inclusion and habilitation of people marginalized by addiction, homelessness, trauma, criminality, incarceration, poverty, racism, sexism, and violence. Amity is committed to research, development implementation, and dissemination of information regarding community building.

Remembrance, Resolution, Reconciliation, Restoration, Renewal

About the Position:

The Enhanced Care Management (ECM) Community Health Worker (CHW) is responsible for care coordination, improving health outcomes, enhancing satisfaction, and reducing unnecessary healthcare utilization. ECM is a comprehensive, student-centered approach to healthcare that aims to improve outcomes for high-need populations.  This involves the coordination of medical, behavioral, and social services to address the full range of student needs, focusing on those with complex and chronic conditions.  ECM programs are designed to optimize care delivery, reduce unnecessary hospitalizations, and improve the overall quality of life for students. The intention of our services is to help people who have not been able to get the needed help in terms of Housing, Mental Health, Substance Abuse treatment, and linkages to community resources to help minimize recidivism. The role of the ECM CHW is to help create a supportive network of services and resources for the client to prevent reincarceration and support long term permanent housing goals.

• The CHW is a field-based member of the ECM Care Team who has lived experience in the ECM Students’ community and serves as the bridge between the ECM Student and the healthcare system.
• Focuses support on ECM Students who are difficult to engage and/or who have cultural or linguistic barriers to care via field-based contacts including accompaniment to appointments.
• Assists the RN Care Manager, BH Care Manager, and Care Coordinator in panel management by performing delegated activities as assigned.
• Assists the ECM Care Team in engagement efforts of eligible ECM Students in the clinic and within the community.
• Assists Students in navigating the healthcare system and community resources.
• Follows up by phone and in person with eligible ECM Students and students enrolled in ECM.
• Helps Students successfully participate in their medical and/or behavioral health care by overcoming barriers to care and sharing information on barriers with the multi-disciplinary team and providers.
• Engages with Students, both in-person and on the phone, in a manner that utilizes evidence-based approaches (such as Motivational Interviewing) and promotes collaboration between the student and their medical/behavioral team.
• Collaborates on Student care issues with other ECM Care Team Members, participating in weekly systematic case reviews and ad hoc case reviews, and consults with Registered Nurse Care Manager and/or the Behavioral Health Care Manager before taking any action that is clinical in nature.
• Accompanies ECM Student to office visits, as needed, and in the most easily accessible setting, within IEHP guidelines.
• Engages Students in the hospital through in-person visits when able.
• Engages those eligible but not yet enrolled, as well as those currently enrolled in ECM, to re-engage for follow-up after discharge.
• Distributes health promotion materials.
• Assists with scheduling Students with other ECM Care Team members as appropriate.
• Connects ECM Students to other social services and supports they may need.
• Advocates on behalf of the Students with healthcare professionals.
• Monitors treatment adherence (including medication and Shared Care Plan goals).

• Excellent interpersonal and communications skills and the ability to work effectively with a wide range of constituencies in the community and within the organization.
• Knowledge of contract parameters, objectives, milestones, and other deliverables.
• Knowledge of contracting process and associated local, state, federal and other regulations.
• Ability to integrate budgetary and service utilization data, forecast expenditures, and respond to ensure both effective provider utilization and budget compliance.
• Ability to multi-task, identify problems, provide recommendations to management teams, and implement any applicable systems.
• Ability to work constructively with diverse people and with parties that may have divergent perspectives and interests.
• Ability to clearly express concepts and direction, both orally and in writing, and to prepare complex reports, policies, and procedures.
• Understand and appropriately apply Amity policies and procedures and adhere to agency-wide practices and regulations.
• Strong oral and written communication skills.
• Proficient with software such as Microsoft Office Suite (Word, Excel. Email, Internet, etc.).

• Medical, Dental, Vision.
• Paid vacation, sick time, & holidays.
• 401K, HSA, & Life insurance programs.
• Organization committed to community action.
• Community oriented workplace.