Vista Community Clinic is a private, non-profit, multi-specialty outpatient clinic providing care in a comprehensive, high quality setting. Located in San Diego, Orange and Riverside counties, we work to advance community health and hope by providing access to premier health services. We are looking for dedicated, motivated, enthusiastic team players who want to make a difference in the community. Our competitive compensation and benefits program includes health, dental, vision, company-paid life, flexible spending accounts and a 403(B) plan, for eligible employees. VCC is an equal opportunity employer.

Operate as part of the patients’ multi-disciplinary care team and responsible for interacting directly with the assigned health plan’s ECM Members and/or family, Authorized Representatives, caretakers and/or other authorized support person(s) as appropriate to coordinate all aspects of ECM and any Community Supports.  Work with the ECM Clinical Nurse Specialist and other program staff to care coordinate designated populations of focus panel to ensure appropriate input is obtained to effectively coordinate all primary, behavioral, developmental, oral health, LTSS, ILOS and other services that address social determinants of health (SDOH). 

• Conduct outreach, enrollment and care management to selected population of focus determined by assigned health plan(s)
• Develop an individualized comprehensive management care plan integrating clinical and non-clinical needs to achieve health goals designed to improve functional status, health status, or prevent decline
• Coach patients and caregivers using evidence-based motivational interviewing techniques and trauma-informed care language to address critical issues to help patients develop achievable self-management care plan goals, presenting     new skills using a step-by-step process
• Act as point of contact for patients and families involved in patients’ care team through any form of agreed-upon communication
• Support patients in the development of health care goals by conducting appropriate assessments that uncover comprehensive physical, mental, social and Community Supports’ needs
• Visit patients in their homes or where they seek care, or prefer to access services in their community using and completing patient interviews on health condition knowledge and motivation to engage in self-management
• Identify and initiate referrals for social service programs, such as financial, community and state supportive services alleviating housing instability and other social determinants of health
• Work with ECM RN Clinical Consultant to monitor medication adherence to include medication management and reconciliation periodically for changes, especially at time of care transitions
• Perform population management tasks such as appointment scheduling, prevention and screening recalls, monitoring referrals, patient portal callbacks and responding to telephone messages

Minimum

• Bachelor’s degree in social work, psychology, counseling, behavioral science
• Two years’ experience in a healthcare setting, preferably providing direct patient care, or with duties involving patient education and advocacy.
• Resourceful community liaison experience navigating through complex health systems and community services
• Bilingual English/Spanish
• Valid CA driver’s license and vehicle insurance, reliable transportation; minimum two years’ driving experience; no more than two violations or a single ticket/accident valued at more than one point on driving record

Preferred Qualifications

• Master’s degree in Social Work (MSW) or other related field
• Experience working with patients with a serious mental illness and/or substance use disorder

Pay Range

• $24.00 - $28.00 per hour DOE