Health & Wellness Coach (Care Coordinator) - LifeLong Medical Care

Community healthcare is highly rewarding. Come join a dynamic care team at LifeLong Medical Care. We are looking for a Health & Wellness Coach at our TRUST Health Center in downtown Oakland. TRUST Health Center’s diverse and unique care team supports health through encouragement, blending medical, mental and social care under one roof. We help people experiencing homelessness in the Bay Area through an intentionally created community where people without their own safe space feel welcomed and accepted. The Health and Wellness Coach provides administrative support to psychosocial services staff and case management services to patients.

This is a full time, 40 hrs/wk, benefit eligible position.

This position is represented by SEIU-UHW. Salaries and benefits are set by a collective bargaining agreement (CBA), and an employee in this position must remain a member in good standing of SEIU-UHW, as defined in the CBA.

LifeLong Medical Care is a large, multi-site, Federally Qualified Health Center (FQHC) with a rich history of providing innovative healthcare and social services to a wonderfully diverse patient community. Our patient-centered health home is a dynamic place to work, practice, and grow. We have over 15 primary care health centers and deliver integrated services including psychosocial, referrals, chronic disease management, dental, health education, home visits, and much, much more. LifeLong Medical Care is an equal opportunity employer. We strongly encourage applications from women, people of color, and bilingual and bicultural individuals and members of the lesbian, gay, bisexual, and transgender communities. Applicants shall not be discriminated against because of race, religion, sex, national origin, ethnicity, age, disability, political affiliation, sexual orientation, gender identity, color, marital status, or medical condition.

Benefits

Compensation: $21 - $23/hour. We offer excellent benefits including: medical, dental, vision (including dependent and domestic partner coverage), generous leave benefits including nine paid holidays, Flexible Spending Accounts, 403(b) retirement savings plan.

COVID-19 Vaccine Policy

In accordance with LifeLong Medical Care's commitment to provide and maintain a workplace that is free of known hazards, we have adopted a Mandatory COVID-19 Vaccine Policy to safeguard the health of our employees and their families; our patients and visitors; and the community at large from infectious diseases, that vaccinations may reduce. This policy will comply with all applicable laws and is based on guidance from the Centers for Disease Control and Order of the California State Public Health Officer. Unless a reasonable medical or religious accommodation is approved, all employees must receive COVID-19 vaccinations.

Care Coordination

1. 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

Health coaching (patient self-management support)

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

2. Assists patients in developing and executing health-related action plans or behavior changes based on client goals

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.

Panel Management

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)

Other Duties 

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.

Job Requirement

• 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.

Job Preferences    

• 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