REPORTS TO: Member and Community Service Unit Manager
SUPERVISES: ISM Program Outreach Worker
ACCOUNTABLE TO: El Monte/Rosemead Health Center Clinic Manager
The Program Coordinator will provide day to day project oversight for the Integrated Service Management (ISM) Program at APHCV. The ISM Program is a collaborative project between physical health, mental health, and substance abuse providers. The ISM Program Coordinator will work with the ISM Project Coordinator at partnering agency, Asian Pacific Family Center (APFC). ISM Program Coordinator will provide enrollment and outreach services to the Chinese communities in the El Monte, San Gabriel, and Rosemead areas. The target population for enrollment and outreach services is the Chinese population with mental health and physical health service needs.
APHCV expects all employees to respond and participate to emergency situation per emergency policies and procedures.
DUTIES AND RESPONSIBILITIES:
1. Maintain all ISM Program files, Community Outreach Support (COS) forms, and other program records.
2. Input and submit COS forms to the APHCV Fiscal Monitor in a timely manner.
3. Maintain minimum 54 target patient enrollment number per fiscal year
4. Submit reports to DMH as requested, including data entry into the iHOMS system.
5. Attend or coordinate meetings with APHCV, APFC and DMH.
6. Facilitate phone conference with ISM Team on a regular basis.
7. Coordinate training for ISM staff relevant to ISM program.
8. Work with MCS Unit Manager to develop workflow and procedures for continuous improvement.
9. Assist MCS Unit Manager in setting up a triage and referral system and resources for ISM eligible clients.
10. Answer and process incoming telephone calls.
11. Provide general administrative support to assigned ISM staff at APHCV and APFC, as needed.
12. Ensure all ISM client records are properly maintained in a HIPAA compliant manner
13. Perform general administrative activities directly related to the ISM program, as assigned.
14. Monitor program budget and make adjustments accordingly.
15. Ensure excellence in customer service.
1. Receive referrals from both Primary Care Physicians (PCP) and APHCV’s ISM partner Asian Pacific Family Center’s (APFC) clients who need access to external resources such as housing, immigration service, legal advice, etc. and link the patient to the appropriate community organization or program in a timely manner (same day when possible).
2. Identify and establish external referral resources for clients, and update regularly.
3. Assess for patient’s needs (i.e. food, shelter, transportation, hygiene, medical, dental, legal counseling, etc.) and provide services or referrals, as needed.
4. Assume a liaison role between APHCV and appropriate community entities including businesses, churches, temples, cultural centers, service organizations, schools, and other community institutions per policies and procedures of APHCV Membership and Community Services Unit.
5. Plan and implement culturally appropriate ISM outreach activities such as health topics and APHCV services. Such plan shall be reviewed and approved by the supervisor.
6. Develop and disseminate culturally and linguistically appropriate health education materials to the community.
7. Provide information and assist with enrollment into benefit programs such as Medi-Cal, My Health LA, Medicare and Medicare Part D, or ISM Indigent Fund enrollment assistance.
8. Develop service plans for those patients who need follow-up with more intensity.
9. Set-up and oversee wellness activities (i.e. workshops, physical activities classes, educational sessions).
10. Record and monitor ISM client eligibility and participation in wellness activities.
Mental Health facilitation:
1. Coordinate with front desk to set primary care appointments with an APHCV physician and also with APFC mental health providers.
2. Work with clinic operation and medical staff to facilitate patient flow.
3. Attends all Mental Health Collaborative and ISM meetings.
• Bachelor’s degree in social work or related field or a minimum of 2 years in patient/client services.
• Ability to work as a member of a team in order to communicate pertinent information to other team members, and support team decisions.
• Ability to communicate effectively and exercise sound and responsible judgment.
• Excellent interpersonal skills, written and verbal. Ability to establish constructive working relationships with all levels of management and employees in a staff of varied and diverse backgrounds.
• Ability to handle difficult or confrontational situations in a calm, consistent, and equitable manner.
• Ability to respond effectively to crisis situations and working knowledge of crisis management techniques and suicide prevention in order to facilitate urgent referral to and coordination with partnering Asian Pacific Family Center.
• Working knowledge of state insurance, social service resources and reporting mechanisms, especially for those in Los Angeles County (including low-income assistance programs for utilities, housing, phone, transportation, and others.)
• Ability to effectively represent the Clinic’s interests in the community; maintaining effective working relationships among public, private and professional groups.
• Demonstrated ability to respond with sensitivity to people of diverse cultures and various lifestyles.
• Working knowledge of Microsoft Office applications.
• Bi-lingual in English and Chinese.
• Prior experience working with homeless, substance using or chronically mentally ill individuals.
Must be able to materially perform the task normally associated with the position including but not limited to: sitting, lifting charts up to 40lbs., typing long hours, and data entry
Belmont Health Center
El Monte/Rosemead Health Center
Los Feliz Health Center
John Marshall High School Health Center *
*Open to JMHS students only.
APHCV's mission is to be the medical home for our patients by providing personalized, quality health care services in a culturally accessible manner.