Description

You will support members with complex medical and social needs by managing a caseload, developing care plans, coaching patients, accompanying them to appointments, and connecting them to community resources. This role focuses on improving health outcomes through education, peer support, and advocacy.

Requirements

• High School Diploma or equivalent
• Bilingual in English and Spanish strongly preferred
• 2+ years of experience with and comfort working with CalAIM populations of focus (people experiencing homelessness, adults with SMI/SUD, adults transitioning from incarceration, adults with complex medical needs)
• Ability to work in a dynamic, outdoors environment
• Ability to work independently as well as part of a team
• Ability to prioritize multiple and competing tasks
• Ability to communicate effectively, including articulating one’s own relevant personal experiences
• Excellent oral communication skills, as well as strong interpersonal skills
• Ability to use computers to document information into case management software
• Travel 50-75% – must have a valid driver’s license, automobile insurance and reliable transportation
• Physical Demands: Work may include both sedentary office duties and active engagement in the field, requiring walking and standing for extended periods.

Responsibilities

• Manage a caseload of patients, including completing assessment forms, developing care plans, and carrying out activities according to the care plan.
• Build rapport with patients to increase likelihood of positive behavior changes.
• Coach patients to minimize risks associated with identified health conditions and behaviors.
• Accompany members to medical and social services appointments.
• Connect members to appropriate programs to address barriers to care and enhance compliance.
• Link members to local, county and state services.
• Follow up with members and serve as a member advocate.
• Introduce systems to promote self-management self-efficacy.
• Document information from every encounter in designated information systems.
• Outreach and engage with eligible patients to enroll them into the Akido ECM Program.