SOCIAL SERVICES CARE COORDINATOR-BILINGUAL

ORGANIZATION

The mission of Ravenswood Family Health Network (RFHN) is to improve the health of the community by providing culturally sensitive, integrated primary and preventative health care to all, regardless of ability to pay or immigration status, and collaborating with community partners to address the social determinants of health.

POSITION SUMMARY

The Social Services Care Coordinator provides care coordination to patients served through the Medication-Assisted Treatment (MAT) and Health Care for the Homeless (HCH) programs and ECM programs. Under the direction of the Department Manager of Social Services, and in collaboration with the Senior Manager of Social Services and HCH Program Manager, the Coordinator supports patients experiencing homelessness, housing instability, alcohol dependence, and complex medical and social needs.

The Coordinator manages an active caseload of approximately 35 patients, completing assessments, developing care plans, coordinating services, conducting outreach, and connecting patients to healthcare, housing, benefits, and other community resources. The Coordinator works closely with the MAT and HCH teams to address barriers to care and social determinants of health while promoting patient engagement, self-advocacy, and independence.

The position utilizes trauma-informed, culturally responsive, patient-centered, motivational interviewing, and harm-reduction approaches and collaborates with internal teams and community partners to support coordinated care and improved patient outcomes.

DUTIES AND RESPONSIBILITIES

To be performed in accordance with RFHN Policies and Procedures

1. Serves as the primary contact to assigned social services members and advocates to help them navigate the healthcare system.
2. Maintains an active caseload of approximately 35+ patients, providing ongoing social services care coordination based on patient needs, acuity, and program requirements.
3. Completes comprehensive social service, psychosocial, and social determinants of health assessments to identify patient needs, strengths, barriers, risks, and available support systems.
4. Develops individualized care plans in collaboration with patients, the MAT treatment team, Health Care for the Homeless (HCH) Program Manager, Senior Manager of Social Services, medical providers, behavioral health staff, and other members of the care team.
5. Provides care coordination to patients participating in the Medication-Assisted Treatment (MAT) program with a focus on alcohol dependence, supporting engagement in treatment and continuity of care.
6. Identifies ECM eligible candidates and refers them to Program Associate and covers for ECM cases as needed.
7. Works collaboratively with the Health Care for the Homeless program to address the unique healthcare and social service needs of patients experiencing homelessness or housing instability.
8. Provides patient outreach and engagement in clinic and community settings, including shelters, housing programs, and other locations where patients may be accessing services.
9. Educates patients about housing resources, eligibility requirements, housing navigation processes, and available supportive housing and homeless services.
10. Connects patients to appropriate housing resources, emergency shelter, transitional housing, permanent supportive housing, coordinated entry, and other community-based services.
11. Identifies and coordinates referrals addressing social determinants of health, including housing, food insecurity, transportation, income, benefits, employment, legal services, behavioral health, alcohol dependence treatment, and other identified needs.
12. Assists patients with accessing public benefits and supportive services, including SSI/SSDI, CalFresh, cash assistance, health insurance, and other available benefits.
13. Assists patients with obtaining documents necessary to access housing, benefits, healthcare, and other services, including identification, birth certificates, financial documentation, and other required records.
14. Supports patients with scheduling appointments, appointment reminders, transportation coordination, referrals, and other activities designed to reduce barriers to healthcare and treatment.
15. Coordinates referrals and follows up with patients and service providers to promote successful connection to recommended services.
16. Provides support during transitions of care, including hospital discharge, emergency department visits, residential treatment, alcohol dependence treatment, and transitions between healthcare and community-based services.
17. Uses trauma-informed, culturally responsive, patient-centered, motivational interviewing, and harm-reduction approaches when working with patients.
18. Educates and supports patients in developing self-advocacy, self-management, and independent skills to navigate healthcare, housing, and social service systems.
19. Advocates for patients and assists in resolving barriers to healthcare, treatment, housing, benefits, and other needed services.
20. Maintains regular communication with patients and, when authorized, family members, caregivers, guardians, or other identified support persons.
21. Participates in interdisciplinary case conferences and collaborates with the Manager of Social Services, Senior Manager of Social Services, HCH Program Manager, MAT treatment team, medical providers, behavioral health staff, and community partners to coordinate patient care.
22. Maintains timely, accurate, and complete documentation of assessments, care plans, patient contacts, referrals, interventions, and outcomes in Epic and other required systems.
23. Maintains documentation and data necessary to meet RFHN, program, county, state, federal, health plan, and funding requirements.
24. Identifies urgent or high-risk patient needs and promptly communicates concerns to the Manager of Social Services, Senior Manager of Social Services, HCH Program Manager, and/or appropriate clinical team member.
25. Maintains current knowledge of community resources and develops effective working relationships with housing providers, social service agencies, healthcare organizations, and other community partners.
26. Participates in supervision, team meetings, training, case conferences, and other meetings as required.
27. Performs other related duties as assigned by the Manager of Social Services.