Community Liaison, Health Plan

Job Description
Position Summary:
Under the direction of Supervisor, Social Services and collaborating closely with MSW/LCSW staff of Social Services and Case Management teams, the Community Liaison is responsible for assisting with community resources and conducting home visits for the IE Campus to offer comprehensive care management to Medi-Cal members with complex medical needs and chronic conditions.
The overall goal of the Community Liaison is to focus on the Triple Aim Health Care Delivery Model designed to improve the health of the population, improve the experience for each individual, and reduce the overall cost of care
The primary focus of the Social Services Community Liaison or is to work with the Social Services team and collaborate with the Case Management team whose mission is to reduce hospital admissions, ED visits, and SNF admissions. This is accomplished by improving member outcomes through coordination of members' physical and mental health, behavioral health care services, social support needs, advance care planning, and connecting them to community services and housing, as needed.
The Social Services Community Liaison is responsible for acting as an advocate for high risk members and assisting members in understanding and navigating the managed care system. The Social Services Community Liaison's role is to lower re-admission rates by visiting members and connecting them to community social supports, long term support services, mental health, substance use disorder services, palliative care, and housing services. This will involve building positive relationships and intensive interactions with them. The Social Services Community Liaison is expected to provide continuous feedback on the members they serve to the MSW/LCSW staff of Social Services team to ensure appropriate steps are taken to improve health outcomes and meet objectives.
Essential Duties and Responsibilities include the following:

• Collaborate closely with MSW/LCSW staff to assist in improving member outcomes by coordinating member's physical and mental health social services and community service linkages.
• Identify specific individual problems, or focused concerns, in collaboration with the member/caregiver to establish the course of action for prioritizing the health action plan (HAP) The goals must be specific to the member and member needs. Also, identify long term goals that will define the criteria for graduation/case closure for HHP members.
• Conduct field visits and follow-ups to high-risk members and their families during and post hospitalizations to support the program's goal of reducing hospital admissions, ED visits, and SNF admissions.
• Maintain frequent, in-person contact and meet in-person visits.
• Engage, educate, and assist members on navigating health, behavioral health, and social services with managed care and connect members to the internal and external resources they need to meet their healthcare needs.
• Establish and maintain positive relationships with members and their families (as needed) to meet health care objectives.
• Assist in identifying resources and eligibility criteria for housing, food security and nutrition, employment counseling, child care, community-based LTSS, school and faith-based services, and disability services, as needed and desired by the member and provide member with information on relevant resources, based on the member's needs and interests.
• Collaborate with the member to ensure needed services are obtained. This may include assisting them in completing transportation applications, IHSS, Cal fresh, Low Income Subsidy, Section 8 Housing and other state/federal program applications and following up to ensure that the services are received.
• Participate and collaborate with the MSW/LCSW staff in providing information regarding care planning barriers to attaining member's goals.
• Indicate the priority of the interventions based on the urgency of the problem or issue, and what is important to the member and/or his family/representative.
• Assist members with scheduling medical appointments and non-emergency medical transportation.
• Assist in coordinating and collaborating with all involved parties to promote continuity and consistency of care.
• Assist members with promoting their self-management skills to increase their ability to engage with Care Team as well as health and service providers.
• Place follow-up calls weekly (50 members * 4 calls per month/20 working days = 10 calls per day).
• Assist in updating assessments, care plans, facilitating service authorizations and scheduling appointments as required.
• Accompany members to appointments as needed.
• Support the achievement of the member's self-directed, individualized health goals to improve their functional or health status, or prevent or slow functional declines.
• Assist the MSW/LCSW staff in integrating community social supports, long term support services, mental health, substance use disorder services, palliative care, and housing services for members enrolled in the program.
• Follow the policies and procedures, workflows, and job aids to support
• Link eligible individuals who are homeless or experiencing housing instability to permanent housing, such as supportive housing.
• Maintain an appointment reminder system for members. This is a recommended best practice only - not a service requirement.
• Document interventions and progress notes
• Provide support for Social Services Management with special projects, if needed
• Demonstrate honesty and integrity in everyday activities.
• Protect privacy for members and employees; ensuring all personal health information is kept confidential-complies with HIPPA regulations i.e., (sensitive papers, charts, and reports are not in view of the public).
• Treat members and their families with respect and dignity.
• Function as liaison between administration, social workers, members, beneficiaries, physicians, and other healthcare providers.
• Interact professionally with other healthcare service providers.
• Communicate appropriately and clearly to management, co-workers, and physicians.
• Consult other departments as appropriate to provide for an interdisciplinary approach to the member/beneficiary's needs
• Participate in the efficient, effective, and responsible use of resources such as supplies and equipment.
• Maintain and continuously update Social Services Resource Directory.
• Know and follow the Employee Handbook policies and procedures.
• Follow the assigned workflow. All assigned work must be completed by the end of business day.
• Perform other duties as assigned by the Social Services Management.

The pay range for this position at commencement of employment is expected to be between $25 - $27 per hour; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.
The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.
Details of participation in these benefit plans will be provided if an employee receives an offer of employment.
If hired, employee will be in an "at-will position" and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.
As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.
Full Time Position Benefits:
The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.
Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.
Health and Wellness:

• Employer-paid comprehensive medical, pharmacy, and dental for employees
• Vision insurance
• Zero co-payments for employed physician office visits
• Flexible Spending Account (FSA)
• Employer-Paid Life Insurance
• Employee Assistance Program (EAP)
• Behavioral Health Services

Savings and Retirement:

• 401k Retirement Savings Plan
• Income Protection Insurance

Other Benefits:

• Vacation Time
• Company celebrations
• Employee Assistance Program
• Employee Referral Bonus
• Tuition Reimbursement
• License Renewal CEU Cost Reimbursement Program
• Business-casual working environment
• Sick days
• Paid holidays
• Mileage

Requirements
Education and / or Experience:

• Undergraduate degree o above required. Social work major desired.
• Minimum two years of related medical or healthcare experience with patient contact.
• Typing 60 words per minutes with accuracy.
• Knowledge of computers, faxes, printers and all other equipment.
• Proficient in Excel, Word and Outlook.
• Ability to deal with responsibility with confidential matters.
• Ability to work in a multi-task, dynamic environment.
• Flexible and adapt to process changes.