Care Coordinator I, HIV & Prevention

POSITION: Care Coordinator I, HIV Testing & Counseling (649)
DEPARTMENT: Community Wellness
REPORTS TO: Program Manager II, HIV & Prevention
LOCATION: Native American Health Center, Inc.
160 Capp Street San Francisco, CA
WORK HOURS: Full Time, 40 hours per week, 100% FTE
STATUS: Non-Exempt, Union

POSITION SUMMARY
The Care Coordinator functions as a member of an integrated care team who will work with providers across NAHC and other systems to provide NAHC clients with access to a holistic system of care. The incumbent will provide care coordination, case management, patient navigation, system navigation (internal and external), peer advocacy, health education, mapping individual, family and community supports and assets, intake (screening and assessments), and group and individual counseling services. The care coordinator may provide evidence-based treatments or work with other mental health providers when such treatment is indicated. The care coordinator may provide training and report writing, when appropriate.

The Native American Health Center is an accredited institution and adheres to the standards of excellence set forth by the Accreditation Association of Ambulatory Health Care (AAAHC) and the Commission of Dental Accreditation (CODA).
 

ESSENTIAL DUTIES AND RESPONSIBILITIES
1. Manage a diverse caseload of adults, youth, and families.
2. Screen and assess patients for common mental health and substance abuse disorders.
3. Facilitate educational groups on a weekly basis. Assist in conducting social service wellness education information group sessions and workshops.
4. Develops and implements individual plans of treatment using a culturally sensitive and strengths-based approach, to assist patients and families to cope and/or restore social, emotional, financial and environmental factors that affect and/or are affected by illness.
5. Monitor patients (in person or by telephone) for changes in clinical symptoms and treatment side effects or complications.
6. Responsible for Maintaining HEP-C and HIV Testing In alignment with NAHC policies.
7. Complete electronic and case management systems documentation related to mental health services in a manner that is both accurate and timely. Ensure completeness and accuracy of required data collection components.
8. Provide early intervention, direct services, and referrals, for clients, including children, adolescents and adults who have been exposed to trauma, mental health issues and/or substance use
9. Facilitate treatment plan changes for patients who are not improving as expected in consultation with the PCP, psychiatric consultant, and other mental health providers. These may include appropriate referrals for additional services.
10. Provide individual, group, and family crisis intervention and aftercare support when needed. Provide emergency services as needed, as well as ongoing case management which may include interacting with other NAHC departments, community agencies and staff.
11. Provide patient education about common sexual health and wellness, mental health and substance abuse disorders and available treatment options. Maintain the highest degree of confidentiality at all times.
12. Represent the program, department and agency in a positive and professional manner at all times.
13. Develop a shared understanding of the respective roles and responsibilities of team members to ensure that collaboration is efficient.
14. Plan and deliver services with an understanding of the healthcare needs of the population being served.
15. Work collaboratively to resolve differing perspectives, priorities and schedules among providers.
16. Connect healthcare consumers and family members to other members of the healthcare team through face-to-face encounters known as “warm hand-offs.” Use behavioral health and general health interventions to support the work of the team and to enhance healthcare consumer outcomes.
17. Clearly convey relevant information in a non-judgmental manner about behavioral health, general health, and health behaviors using person- centered concepts and terms that are free of jargon and acronyms and are easily understood by the listener.
18. Measure and monitor individual health outcomes in collaboration with the consumer, adjusting care plans based on outcome data.
19. Monitor healthcare consumer care on multiple dimensions and adjust care and practice patterns based on the feedback.
20. Effectively connect healthcare consumers who cannot be adequately treated by the team or within the setting to other appropriate services.

ADVOCACY
21. Support and closely coordinate mental health care with the integrated system of care.
22. Refers participants and their families to appropriate community agencies or facilities; acts as liaison with such organizations and advocates for patients and/or their families.
23. Introduce evaluation activities to families, attain consent for participation in evaluation, and gather baseline and follow-up data through the administration of questionnaires.
24. Support HIV Preventative medication management prescribed by PCPs, focusing on treatment adherence, side effects and other complications, and effectiveness of treatment.
25. Facilitate patient engagement and follow-up in care.
26. Facilitate referrals for clinically indicated services outside the primary care clinic (e.g., social services such as housing assistance, vocational rehabilitation, mental health specialty care, substance abuse treatment).
27. Member Care: Demonstrate understanding and apply working knowledge of safety policies and ensuring safe member practices.
28. Employee Safety: Safely performs all duties; follows required protective protocols to ensure personal safety as well the safety of others.
29. Must maintain compliance with ergonomic safety standards; be mindful of posture and regularly practice ergonomic stretches.
30. Quality Improvement: Actively participate in internal quality improvement teams and work with members proactively to drive quality improvement initiatives in accordance with the mission and strategic goals of the organization, federal and state laws and regulations, and accreditation standards, when assigned.
31. HIPAA: Keep all protected health information (PHI) confidential and abide by HIPAA policies for the release and disclosure of any PHI. Will report unauthorized use of disclosure of PHI immediately, to supervisor or HIPAA security officer.
32. Work well under pressure, meet multiple and often competing deadlines.
33. At all times demonstrate cooperative behavior with supervisors, subordinates, colleagues, clients and the community.
34. Other duties as assigned by Supervisor and Director of Community Wellness Department.

MINIMUM QUALIFICATIONS
1. High school diploma or equivalent.
2. At least 6 months experience providing care coordination services, counseling, or case management services. Excellent writing and facilitation skills.
3. Demonstrates understanding of the principles of behavioral and primary health care integration.
4. Knowledge of the Bay Area Native American community with a commitment to serving Native Americans and other vulnerable patient populations including LGBTQ2Spopulations.
5. If in recovery, 3 or more years of sobriety.
6. Must have a valid California Driver’s License. Ability to travel across
Alameda County in personal vehicle.
7. Knowledge of funding, community resources/services and clinical standards is required.
8. Experience working with vulnerable, underserved, homeless and transient populations.
9. Experience working with patients who have co-occurring mental health,
substance abuse, and physical health problems.
10. Must meet standards of character under PL 101-630, section 408, Character Investigation, subsection (a) and PL 101-647, section 231, Requirement for Background Check, subsection (c), and agree that employer can contact the last two employers, the sex abuse detective division of local law enforcement and Child Protective Services of the last two counties in which the person has lived or worked to inquire as to the suitability of the person to work with children.
11. Vaccination Level 1: Must be able to provide TB, Physical, seasonal flu and proof of Vaccination immunity for Measles, Mumps, Rubella, Varicella, TDAP & Hepatitis B, prior to start date. If vaccination records are more than 10 years old, titers are required to confirm immunity.
12. BLS/CPR certification must be obtained prior to start date and kept current at all times.

PREFERRED QUALIFICATIONS
1. Bachelor’s degree in Public Health, Social Work, Health Education or other related fields.
2. Bilingual in Spanish preferred.
3. Cultural knowledge related to Indigenous populations of the SF Bay Area.
4. Working knowledge of differential diagnosis of common mental health and/or substance use disorders, when appropriate.

PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this Job, the employee is regularly required to sit and use hands to finger, handle, or feel. The employee is frequently required to talk or hear. The employee is frequently required to stand; walk; reach with hands and arms and stoop, bend at waist, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus.

WORKING CONDITIONS AND ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly exposed to both an inside/outside environment and may be exposed to the burning of traditional medicines.

Note to Applicants: Please be advised a post job offer, pre-employment Physical, TB test and Vaccination Clearance are required as a condition of employment. Vaccination Levels: 0 – Limited - require only TB, Physical & Seasonal Flu; 1 – Full Panel with exposure of Blood Borne Pathogens – requires, Measles, Mumps, Rubella, TDAP, Varicella, Hepatitis B, TB, Physical & Season Flu; 2 – Full panel no exposure of Blood Borne Pathogens – requires Measles, Mumps, Rubella, TDAP, Varicella, TB, Physical & Seasonal Flu. Additionally, you may be asked to get a Department of Justice Fingerprinting and/or Federal, State, County criminal background check clearance as a contingency for an offer of employment. Criminal clearances are obtained to protect the welfare and safety of clients receiving services at NAHC.

EQUAL OPPORTUNITY EMPLOYER: Within the scope of Indian Preference, all candidates will receive equal consideration without regard to race, color, gender, religion, national origin or other non-merit factors.

Age Discrimination in Employment Act (ADEA): Native American Health Center abides by the mandates of the ADEA (protecting individuals 40 years and older) and considers age a non-merit factor in all employment decisions and considerations.

Americans with Disabilities Act (ADA): Native American Health Center abides by the mandates of the ADA and considers disability a non-merit factor in all employment decisions and considerations. Furthermore, NAHC will make any practical, feasible, and reasonable arrangements to accommodate qualified applicants and employees with disabilities.