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  Primary Care Coordination

• Tracks patients’ progress and alerts providers to need for enhanced services according to clinic prioritization
• Provides short term case management services
• Assists with patient specific barrier removal
• Eligibility determination to ensure access to community services
• Troubleshooting around medications, transportation, benefits
• Available to provide community accompaniment for vulnerable patients in collaboration with care team
• Tracks, manages, and facilitates specialty referrals to ensure patients successfully follow-up
• Makes appointments and completes reminder calls for primary care provider panel
• Assists with medication reconciliation

2. Integration of Care (Medical and Psychosocial)

• Accepts warm hand offs of patients between Medical and Behavioral Health providers to facilitate integration of care.
• Coordinates behavioral health referrals and collaborates with patient’s community behavior health providers
• Maintains active list of relevant community resources and places appropriate referrals
• Familiar with basic local housing and shelter resources for provision to patients

1. Coaches patients in self-management (e.g. medication adherence, lifestyle)

3. Navigates problem-solving with patients as they encounter obstacles to achieving health-related goals

4. Conducts brief interventions with patients regarding alcohol and tobacco use and other behavioral health issues as appropriate.

1. Maintains accurate provider panel in Electronic Health Record with active patient definition

2. Maintains chronic disease registries and targets patients for chronic care management activities at regular intervals such as

• Retention in care
• Chronic disease related education referrals
• Chronic disease related preventative tasks (use of standing orders)

1. Actively participates in team meetings with internal staff and external partners

2. Contributes to clinic quality improvement planning and implementation

3. Responsible for data collection, entry and generation of reports

4. Coordinates operation of special projects as assigned by Center Manager

• Strong organizational, administrative and problem-solving skills, and ability to be flexible and adaptive to change while maintaining a positive attitude.
• Ability to prioritize tasks, work under pressure and complete assignment in a timely manner.
• Ability to effectively present information to others, including other employees, community partners and vendors.
• Ability to seek direction/approval from on essential matters, yet work independently with limited onsite supervision, using professional judgment and diplomacy.
• Work in a team-oriented environment with a number of professionals with different work styles and support needs.
• Excellent interpersonal, verbal, and written skills and ability to effectively work with people from diverse backgrounds and be culturally sensitive.
• Conduct oneself in external settings in a way that reflects positively on LifeLong Medical Care as an organization of professional, confident and sensitive staff.
• Ability to see how one’s work intersects with that of other departments of LifeLong Medical Care and that of other partner organizations.
• Willingness to cross-train and perform the functions of financial eligibility, cashiering and telephone operations.
• Make appropriate use of knowledge/ expertise/ connections of other staff.
• Be creative and mature with a “can do”, proactive attitude and an ability to continuously “scan” the environment, identifying and taking advantage of opportunities for improvement.
• Commitment to working directly with low-income persons from diverse backgrounds, in a helpful, supportive manner.

• Administrative experience in health or social service setting.
• Knowledge of East Bay health and social service resources.
• Previous work providing services to persons who are disabled, homeless, substance users, and/or psychologically impaired.
• Proficient in Microsoft office word with ability to manage databases.

• 2 years’ experience with essential duties above.
• Bachelor’s Degree in Social Work, Health or Human Services field.
• Demonstrated ability and sensitivity to provide services to persons who are disabled, homeless, substance users, HIV (AIDS) infected, and/or psychologically impaired.
• Bilingual in English/Spanish a plus