Job Description

IOA is on the forefront of revolutionary healthcare models, reshaping the way people can age in place. Our innovative models transform lives, enhance communities, and save healthcare systems millions of dollars. Rather than focusing on archaic outdated design, we strive to consistently question the “status-quo” and create new and more innovative ways to help aging adults and adults with disabilities maintain their quality of life. With over 23 programs, we offer multiple ways to aid seniors maintain their health, well-being, independence and participation in the community, fulfilling our mission. BILINGUAL IN SPANISH & ENGLISH PREFERRED. Provides care coordination support with a preventative health focus to CalAIM clients working in conjunction with the assigned Lead Care Manager. Ensures clients’ connectivity to health care services by breaking down the barriers to accessing the health care system for clients with multiple biopsychosocial needs. RESPONSIBILITIES: Maintains regular contact with assigned clients to ensure referred services are being delivered. Completes referrals and follow-up calls regarding on-going connectivity to primary care clinics, behavioral health providers, home health agencies, durable medical equipment companies, and/or other health care services. Conducts outreach and engagement activities for newly referred/authorized potential clients by meeting them where they are whether that be at home, in a hospital or nursing facility or in a shelter/on the street. Provides education to clients about health and mental health care and systems in a culturally appropriate manner that addresses potential barriers to engagement. Conducts home visits, acute hospital & skilled nursing facility visits, as well as escorts clients to medical and other appointments as clinically indicated. Assists Lead Care Manager in completing necessary documentation to enroll and maintain Medi-Cal waiver participation for clients (such as California Community Transitions & Assisted Living Waiver programs). Identifies, arranges for, and monitors appropriate community services based on a solid knowledge of Medicare, Medi-Cal, and other entitlement programs. Establishes and maintains a professional relationship with clients and their informal support network as appropriate, offering respect, dignity and support. Documents via progress notes all client-involved activity regarding identified problems within 24-48 hours, as needed. Maintains required paperwork and follows a clear, concise, and consistent system of charting to allow for continuity of care. Establishes and maintains open and effective communication with community providers, including physicians and other health care and social service workers. Provides appropriate information on all significant aspects of individual client care and program operations, while maintaining necessary confidentiality. Working closely with the entire interdisciplinary team, particularly as it pertains to clients’ ability to maintain living in the community. Attends and actively participates in team and program meetings, activities and problem-solving endeavors; contributes to open lines of communication within the team. Utilizes supervision appropriately; maintaining open lines of communication and providing updates on client activity. Understands and applies the regulatory and procedural requirements of the Institute on Aging. Attends continuing education classes and/or inservice training to increase knowledge, skills and attitudes related to case management, gerontology, family and community systems and other areas relevant to the client population. All other reasonably related responsibilities as assigned. EDUCATION: HS Diploma, Community Health Worker certificate preferred. BACKGROUND AND EXPERIENCE: At least 2 years experience working as a Community Health Worker or equivalent. Lived experience navigating the health care system living with a disability or complex medical/behavioral health condition. Familiarity and experience with the cultural and geographic demographics of the population served. Experience with and understanding of the medical and psychosocial problems of functionally impaired adults and older adults. Experience working with individuals with mental and/or behavioral health diagnoses and substance abuse disorders highly desired. Detail oriented with good problem-solving skills and the ability to prioritize multiple tasks. Computer literacy required.

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