ECM Care Coordinator - CONTRACT

Posting number: 26-ECMCC-01

Department: Multiple County Departments

Job classification: Contract-Benefits

Posting type: Open

Categories: Health Services

Summary

San Bernardino County invites qualified professionals to apply for the position of Enhanced Care Management (ECM) Care Coordinator for Arrowhead Regional Medical Center, the Department of Behavioral Health, and the Department of Public Health. Care Coordinators work in County health clinics, community behavioral health clinics, field settings, and institutional environments to help children, adolescents, families, and adults with complex medical, behavioral health, and substance use needs connect to resources and support that improve their overall well-being. Applicants willing to work in hospital, clinic, home, forensic, and criminal justice settings, including after-hours or nontraditional schedules are encouraged to apply.

Duties include, but are not limited to:

• Conduct a daily scrub of eligible/enrolled ECM patients to identify those coming into the clinic for a primary or specialty care visit and engage with patient during the visit, including screenings and assessments as appropriate.
• Conduct a daily scrub of hospital inpatient census and patient alerts in Care Director to identify patients with new hospitalization/discharge and/or emergency department visit who need to be followed up with by an ECM team member.
• Carry a caseload of ECM patients, providing care coordination and assistance with physical, mental and social support services, including appointment scheduling and referral management.
• Participate in SCR meetings, including presenting assigned patients for further review and follow up as appropriate for the ECM program. 
• Build supportive, working relationships with patients to fully understand patient's needs and deficits from patient's perspective, including developing improvement plans with the patient for physical, mental, and social health needs. 
• Conduct appropriate assessments including, but not limited to Comprehensive Health Assessments and Patient Health Questionnaire - 9, as required per the ECM program.
• Ensure engagement attempts and completion of tasks related to metrics for assigned patients are met routinely.
• Build supportive working relationships with ECM patients to understand the needs and deficits from patient’s perspective.
• Evaluate patient’s levels of health literacy and “translate” communications with providers and nursing staff.
• Provide ongoing evaluation of patient needs and referral to appropriate resources to address social determinates of health.
• Provide assistance in applying for and connecting with public and community benefits and resources, including educating patients on qualifying criteria for various benefits and resources.
• Drive personal and/or County vehicle throughout San Bernardino County, and at times outside of this area, for patient visits and appointments.
• Provide warm hand offs to other ECM team members as appropriate to enhance patient care.

Enhanced Care Management with County Logo and mountain and sun background

The Enhanced Care Management (ECM) benefit is a foundational component of CalAIM. ECM is a whole-person, interdisciplinary approach to comprehensive care management that addresses the clinical and non-clinical needs of high-cost, high-need managed care members through systematic coordination of services that is community-based, interdisciplinary, high-touch, and person-centered.

The ECM program is a collaboration between the following San Bernardino County departments: Arrowhead Regional Medical Center, Department of Behavioral Health, Department of Public Health, Sheriff's Department, and the Probation Department.

The contract position receives the following benefits:

• Holiday leave
• Sick leave
• Vacation leave
• Participation in the County's PST retirement system
• Eligible to participate in the County's 457(b) Salary Savings Plan
• Eligible to participate in the Dependent Care Assistance Plan
• Eligible to participate in the Flexible Spending Account