Hourly Serene Health Jobs (NOW HIRING)

Job Summary: 

The official job title is Senior Community Support Outreach Specialist. 

The Senior Community Support (CS) Outreach Specialist organizes and oversees the work of the team of CS Outreach Specialists and supports the care of members enrolled in the Community Support program. The goal of the Community Support program is to effectively manage high-utilizers and homeless members to ensure that their housing needs are met for a well-managed, whole person care approach and to minimize the likelihood of preventable hospital admissions and emergency department utilization. The Senior CS Outreach Specialist will work to accomplish this program's goal in coordination with the CS Leadership team and input from the CS Outreach Specialist team. This role is fully in-office to attend in-person work-related events, trainings, and meetings and to further ensure teamwork, collaboration, and innovation. 

Responsibilities: 

• Coordinate the enrollment, communication for, and administer in-house training sessions. 

• Provides care management services to own caseload of patients in line with CS - DHCS guidelines and recommended services. 

• Conduct regular case plan reviews to ensure that quality services are provided and documented by CS Outreach Specialists, consistently and accurately, as per established workflows. 

• Provides support and coaching to CS Outreach Specialists in the resolution of patients' issues. 

• As needed, collaborates in care management workflows in health plan databases and Alliance portal to review documentation and improve productivity and reimbursements. 

• Consults with all internal and external Supports teams to ensure that enrolled members experiencing homelessness or at risk for homelessness receive housing navigation and other related services. 

• Actively participates in program performance improvement and evaluation initiatives. 

• Outreach and enrollment, timely and accurate completion of comprehensive housing assessments and care plans, and monthly reporting. 

• Facilitates a team approach, including all participants of the Enhanced Care Management (ECM) team. 

• Conducts face to face visit with members, when shadowing newly hired CS Outreach Specialists. 

• Contribute to the success of the organization by participating in quality improvement activities. 

• Document as necessary in required Electronic Medical Record portals and Managed Care Plan portals for all care coordination and other services or teaching provided in a timely manner. 

• Maintain current knowledge of policies and procedures related to safe work practices. 

• Maintain the privacy of all patients, employees, and volunteer information and access such information only on a need-to-know basis for business purposes. 

• Perform additional duties as assigned. 

Community Support (CS) Services: 

• Housing Transition Navigation Services: Members experiencing homelessness or at risk of experiencing homelessness receive help to find, apply for, and secure housing. 

• Housing Tenancy and Sustaining Services: Members receive support to maintain safe and stable tenancy once housing is secured, such as coordination with landlords to address issues, assistance with the annual housing recertification process, and linkage to community resources to prevent eviction 

• Recuperative Care (Medical Respite): Members with unstable housing who no longer require hospitalization but still need to heal from an injury or illness, receive short-term residential care including housing, meals, ongoing monitoring of the member's condition and coordination of transportation to appointments.  

• Caregiver Respite Services: Short-term relief for caregivers of members. Members may receive caregiver services in their home or in an approved facility on an hourly, daily, or nightly basis as needed. 

• Community Transition Services/ Nursing Facility Transition to a Home: Members transitioning from a nursing facility to a private residence where they will be responsible for their own expenses, receive funding for set-up services such as security deposits, set-up fees for utilities, and health-related appliances, such as air conditioners, heaters or hospital beds. 

• Environmental Accessibility Adaptations (Home Modifications): Members receive physical modifications to their home to ensure their health and safety and allow them to function with greater independence. 

• Sobering Centers: Members who are found to be publicly intoxicated are provided with a short-term, safe, supportive environment in which to become sober. Medical triage, a temporary bed, meals, substance use education and counseling, and linkage to other health care services.  

• Housing Deposits: Members receive assistance with housing security deposits, utilities set-up fees, first and last month's rent, and first month of utilities.  

• Short-Term Post-Hospitalization Housing: Members who do not have a residence, and who have high medical or mental health and substance use disorder needs, receive short-term housing for up to six months to continue their recovery.  

• Day Habilitation Programs: Members who are experiencing homelessness, are at risk of experiencing homelessness, or formerly experienced homelessness, receive mentoring by a trained caregiver on the self-help, social, and adaptive skills needed to live successfully in the community.  

• Personal Care and Homemaker Services: Members who require assistance with Activities of Daily Living receive in-home support. 

• Nursing Facility Transition/ Diversion to Assisted Living Facilities: Members living at home or in a nursing facility are transferred to an assisted living facility to live in their community and avoid institutionalization in a nursing facility, when possible.   

• Medical Supportive Food/ Meals/ Medical Tailored Meals: Members receive deliveries of nutritious, prepared meals and healthy groceries to support their health needs.  

• Asthma Remediation: Members receive physical modifications to their home to avoid acute asthma episodes due to environmental triggers like mold.  

Education and Experience: 

• High school, diploma or GED is required. Bachelor's degree preferred. 

• Minimum of 6 months experience of CalAIM CS Outreach Specialist experience required. 

• Minimum of 1 year experience as a Medical Assistant, CNA, EMT, other healthcare experience or customer service experience required. 

Required Skills/Abilities:  

• Must have a valid California driver's license and valid vehicle insurance. 

• Basic computer literacy, including electronic medical record documentation and patient follow-up. Proficiency in Microsoft Office and related software. 

• Knowledge of medical terminology and familiarity with spreadsheets, databases, and office equipment. 

• Bilingual in English/Spanish preferred. 

• Ability to collaborate with diverse patients with strong cultural sensitivity. 

• Excellent organizational, time-management, and detail-oriented skills. 

• Leadership skills and ability to multitask, prioritize, and meet deadlines. 

• Independent resource-seeking and collaboration skills; ability to work independently and in a team. 

• Effective communication, interpersonal skills, and customer service focus. 

• Strong writing, presentation, and data interpretation skills. 

• Ability to manage stress, conflict, and crises effectively. 

• Flexible, adaptable, and self-disciplined in various settings. 

• Experience with Motivational Interviewing or empathy-based communication. 

• Sensitivity to multicultural communities and mental health/addictive disorders. 

• Commitment to high-performance team practices and continuous improvement. 

Physical Requirements:  

• Must be able to travel using personal vehicle to complete outreach visits. Mileage reimbursement for the use of your vehicle is at a standard rate. 

• Must successfully complete and maintain current Tuberculosis (TB) testing and clearance in accordance with company policy and applicable local/state health regulations as a condition of employment. 

• Prolonged periods of sitting at an office desk on the computer. 

• Lifting: Able to lift up to 15lbs.