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Job Title: BHCC/ECM
Department: ECM
FLSA Status: Non-Exempt
Reports To: Director of Case Management
Hours:  4/10 shift, either Mon-Thurs or Tue-Fri TBD
Location: Round Mountain

POSITION SUMMARY

Under general supervision, the Integrated Care Coordinator/ECM provides comprehensive, person-centered care coordination to individuals enrolled in Hill Country Community Clinic’s Enhanced Care Management (ECM) program. This position works collaboratively with patients, medical and behavioral health providers, community partners, health plans, hospitals, specialists, and other members of the patient’s care team to address medical, behavioral health, social, and community support needs.

The Integrated Care Coordinator/ECM manages a caseload of complex care patients and provides services in the clinic, by telephone or other approved communication methods, and in community or home-based settings as appropriate. Responsibilities include completing assessments, developing and maintaining individualized care plans, coordinating services, supporting transitions of care, addressing barriers to treatment, and connecting patients with appropriate healthcare and community resources.

This position requires the ability to work effectively with individuals experiencing complex medical, behavioral health, substance use, housing, and social challenges. Services are provided using trauma-informed, harm reduction, motivational interviewing, and person-centered approaches. The Integrated Care Coordinator/ECM meets patients where they are, promotes patient choice and self-determination, and provides respectful, nonjudgmental, culturally responsive services.

The Integrated Care Coordinator/ECM is a billable ECM provider position. Timely, accurate, and complete documentation within the Electronic Health Record (EHR), including appropriate service, diagnosis, time, and billing documentation, is an essential function of this position.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Other duties may be assigned based on program and organizational needs.

1. Engage eligible and enrolled ECM patients and develop trusting, person-centered working relationships.
2. Complete comprehensive assessments to identify medical, behavioral health, social, housing, transportation, medication, and other care coordination needs.
3. Collaborate with patients to develop, implement, and regularly review individualized care plans, goals, interventions, and identified needs.
4. Provide ongoing ECM services in accordance with program requirements, patient acuity, individualized care plans, and identified needs.
5. Coordinate care with primary care providers, behavioral health providers, specialists, hospitals, pharmacies, social service agencies, Community Supports providers, and other members of the patient’s care team.
6. Conduct outreach and follow-up through approved methods, including telephone, electronic communication, clinic visits, community-based contacts, and home visits when appropriate.
7. Support patients with scheduling and attending medical, behavioral health, specialty, and other necessary appointments. Follow up on missed appointments and assist patients in addressing barriers to care.
8. Assist patients with transitions of care following emergency department visits, hospitalizations, skilled nursing stays, or other changes in level of care, including timely follow-up and coordination with the care team.
9. Connect patients with appropriate community resources and benefits related to housing, food, transportation, financial assistance, social services, behavioral health, substance use treatment, and other identified needs.
10. Provide health promotion, health education, coaching, and support related to self-management goals, medication adherence, treatment plans, preventive care, and overall wellness.
11. Utilize motivational interviewing, trauma-informed care, harm reduction principles, and appropriate de-escalation techniques when working with patients.
12. Advocate for patients and assist them in navigating healthcare, behavioral health, social service, and community systems.
13. Participate in interdisciplinary care coordination and communicate significant changes in patient needs, barriers, risks, or care plans to appropriate members of the care team.
14. Complete all required ECM enrollment, assessment, care planning, reassessment, transition, and discharge documentation in accordance with organizational, health plan, and program requirements.
15. Document all patient contacts, outreach attempts, care coordination activities, interventions, referrals, outcomes, and follow-up plans accurately and timely in the EHR.
16. Utilize appropriate diagnosis codes, service codes, time units, and other required billing elements in accordance with ECM and organizational requirements.
17. Maintain required patient contacts and documentation based on program standards, patient acuity, individualized needs, and established care plans.
18. Attend and actively participate in all required and mandatory trainings, including maintaining required certifications and completing assigned training within established timeframes.
19. Attend and actively participate in bi-weekly Case Management Department meetings, ECM/program meetings, interdisciplinary care team meetings, case conferences, and other organizational meetings as assigned.
20. Participate in chart audits, quality assurance and quality improvement activities, program monitoring, corrective action activities, and other compliance-related activities as required.
21. Maintain current knowledge of ECM requirements, Hill Country programs, Community Supports, community resources, and other healthcare and social service programs available to patients.
22. Assist with outreach, data collection, program reporting, quality improvement initiatives, and grant-related activities as assigned.
23. Maintain patient confidentiality and comply with HIPAA, applicable privacy requirements, organizational policies, and program standards.
24. Demonstrate flexibility and the ability to reprioritize responsibilities in response to urgent patient, clinic, or program needs.
25. Perform other duties as assigned.

SUPERVISORY RESPONSIBILITIES

This position has no supervisory responsibilities.

BEHAVIORAL AND PROFESSIONAL STANDARDS

The Integrated Care Coordinator/ECM is expected to:

• Adhere to Hill Country Community Clinic policies and procedures.
• Maintain patient privacy and confidentiality.
• Perform duties ethically, professionally, and within the scope of the position.
• Work collaboratively as part of an interdisciplinary team.
• Demonstrate respect, compassion, professionalism, and appropriate boundaries.
• Use time efficiently and maintain timely documentation.
• Demonstrate flexibility and the ability to reprioritize responsibilities.
• Provide culturally responsive, trauma-informed, person-centered services.
• Maintain a safe and professional work environment.
• Accept feedback and participate in ongoing training and professional development.
• Perform job duties accurately and in accordance with applicable program requirements.

QUALIFICATIONS

The requirements listed below are representative of the knowledge, skills, and abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and Experience:

• High school diploma or equivalent required; Associate degree or higher in health, behavioral health, social services, human services, or a related field preferred.
• One to three years of relevant experience in case management, care coordination, healthcare, behavioral health, social services, community health, or a related setting preferred.
• Experience working with individuals with complex medical, behavioral health, substance use, housing, or social service needs preferred.
• Strong written and verbal communication skills.
• Ability to work collaboratively with patients, healthcare professionals, community organizations, and multidisciplinary teams.
• Experience with an Electronic Health Record (EHR) or similar documentation system preferred.
• Ability to maintain accurate, timely, and detailed documentation.
• Knowledge of community resources and healthcare and social service systems is preferred.

CERTIFICATES AND LICENSES

• Current CPR certification or ability to obtain within the timeframe required by Hill Country.
• Current valid California driver's license and ability to meet organizational driving requirements when driving is an essential function of the position.

LANGUAGE ABILITY

Must possess effective verbal and written communication skills. Ability to read and interpret policies, procedures, safety information, program requirements, and other job-related documents. Ability to prepare routine reports and correspondence and communicate effectively with patients, employees, healthcare professionals, community partners, and other stakeholders.

MATH ABILITY

Must possess basic math skills, including the ability to add, subtract, multiply, and divide using whole numbers, fractions, and decimals and calculate rates, ratios, and percentages as necessary.

REASONING ABILITY

Must possess intermediate reasoning and problem-solving skills. Ability to apply common-sense understanding to carry out written and verbal instructions, prioritize competing responsibilities, and respond appropriately to a variety of patient and program situations.

COMPUTER SKILLS

Must possess a good working knowledge of Windows operating systems, Microsoft Office applications, including Word, Excel, and Outlook, internet browsers, and related software. Must demonstrate proficiency or the ability to become proficient with Hill Country’s Electronic Health Record and other required healthcare, care coordination, and documentation systems.

EQUIPMENT SKILLS

Ability to effectively use computers, copiers, scanners, printers, multi-line telephone systems, mobile devices, and other standard office and healthcare equipment necessary to perform assigned duties.

WORK ENVIRONMENT

This position operates in medical clinics, office, community, and field-based environments. Duties may include travel to patient homes, community agencies, healthcare facilities, hospitals, and other community locations.

The employee may encounter individuals experiencing medical, behavioral health, substance use, housing, or other complex circumstances. The employee is expected to follow all organizational safety procedures and use appropriate professional judgment when providing community-based services.

Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

PHYSICAL DEMANDS

The physical demands described here are representative of those required to successfully perform the essential functions of this position.

While performing the duties of this job, the employee regularly uses hands to handle or operate equipment and frequently communicates verbally. The employee frequently sits, stands, walks, and reaches with hands or arms. The employee may occasionally balance, stoop, kneel, or crouch.

The employee will frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. The position requires appropriate visual abilities to perform documentation, driving, computer, and other job-related responsibilities.

Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.