Case Coordinator (Part-Time)

POSITION: Case Coordinator

STATUS: Non-exempt; Part time

REPORTS TO: Behavioral Health Providers and Medical Director

OFFICIAL DUTY STATION(S): Belmont Health Center (180 Union Place, Los Angeles, CA 90026) and El Monte/Rosemead Health Center (9960 Baldwin Place, El Monte, 91731)


Social Services:

  1. Receive referrals from both Primary Care Physicians (PCP) and Licensed Clinical Social Worker’s client/patients who need access to external resources such as housing, immigration service, legal advice, etc. and link the client/patient to the appropriate community organization or program.
  2. Make necessary contact and establish contacts with external resources for client/patients as directed by the LCSW for higher levels of Psychiatric care
    1. Includes helping during mental health emergencies to prepare documentation for care and at times monitoring client/patient.
  3. Assist LCSW with suicidal client/patient, respond immediately for need of referral to shelter/housing of indigent client/patient.
    1. In the event Case Coordinator needs to rarely stay past normal working hours due to a crisis, compensatory time off will be granted.
  4. Track referrals to Psychiatry for completion
    1. Ensure client/patient went for specialty consultation
    2. Obtain consultation note outcomes prior to next LCSW visit
  5. Help assess Client/patient’s for basic needs (i.e. food, shelter, transportation, hygiene, medical, dental, legal counseling, etc.) and provide services or referrals as needed.
    1. This includes maintaining resource lists of enabling and supportive services for English speaking as well as limited English proficiency clients/patients.
  6. Refer to Enrollment Staff as needed to provide Medi-Cal, Managed Care, Medicare or Medicare Part D enrollment assistance.
  7. Develop service plans for those client/patients who need follow-up with more intensity.
  8. Document and maintain records of all client/patient encounters.
  9. Develop and maintain a referral system with the different departments of the clinic.
  10. Update outside referral resources on an on-going basis.
  11. Serve as back-up Interpreter when needed.

Mental health:

  1. The Case Coordinator will have access and knowledge of specific facts about a patient’s history and mental health diagnosis, thus must adhere to HIPAA requirements to keep patient information confidential.
  2. Make calls to Client/patients to determine if they have tried recommendations made by Social Worker.
    1. Encourage application of those coping mechanisms
    2. Make earlier appointments for those who are deteriorating.
  3. Coordinates with front desk to set mental health appointments for Behavioral Health Consultant
  4. Coordinates mental health visits; tracks client/patient no-shows, conducts follow-up and reminder phone calls for all mental health client/patients.
  5. Work with clinic operation and medical staff to facilitate client/patient flow.
  6. Act as back-up for transfer of client/patients to Psychiatric care in the absence of LCSW.
  7. Administers Client/patient Health Questionnaire-9 (PHQ-9) Depression Assessment tool for all new mental health client/patients and at least every month for those who are under treatment with diagnosis of depression
    1. Track progress of client/patients and help alert LCSW of client/patients who are deteriorating.
    2. Generate quarterly summary of progress in PHQ-9 for all actively treated client/patients with help of IT/IM staff for LCSW
    3. Send summary to Medical Director who then reviews and presents to TQM Committee and Board QI Committee.
  8. Help administer other tests such as GAD-7 anxiety questionnaire, Alcohol and Drug use surveys forScreening, Brief Intervention, and Referral to Treatment (SBIRT).
  9. Other tasks as defined by LCSW and Medical Director




Schedule client/patients and remind client/patients 1 week before visit and 2 days before visit to minimize “No Shows”

Assist LCSW

Assist in helping LCSW stay on track during day with reminder if interaction with patients exceeds scheduled visit time

Referral to help obtain coverage

Refer to Enrollment staff to obtain coverage for mental health and primary care

Limited Test administration and retesting under LCSW supervision

PHQ-9, GAD-7, abbreviated mini mental, alcohol and drug use tests and retest to assess efficacy of interventions

Client follow-up phone calls weekly to help reinforce self-management

Ask how they are doing and log response.

Encourage ongoing solutions finding and positive task accomplishment

Forms Completion

Fill out demographics on DMH mandated forms to assist LCSW

Communicating and Referrals tracking

Transmit results to Providers; make contact with Psychiatrist for LCSW, Provider, and facilitate conference calls when needed. Track completion by Patient of visit. Obtain report.

Obtain Consultation notes from specialists for LCSW and PCP’s

These are to be done before follow-up visit with LCSW

Side effect surveillance

Ask client/patient if there are adverse side effects and communicate with LCSW and Provider

Track PHQ-9 and GAD-7 scores

Track client/patients and their progress over time and provide tracked summary to LCSW and Medical Director (with help of IT/IM)

Prepare trend reports

Needed for Medical Director Quality Assurance analysis and tracking patients who are not responding to care

SUMMARY: The Case Coordinator (CC) will work in collaboration with the mental health team, which consists of the Medical Director and Licensed Clinical Social Worker (LCSW). The CC is responsible for delivering accurate information about the APHCV’s programs and community social services to client/patient seeking services. The CC is also responsible for providing short-term service plan for the referred client/patients as related to utilization/ follow-up of external community resources. The CC will focus on APHCV’s integrated mental health program and treats APHCV client/patients as priority. In no event 10% of her clients shall be community clients.

APHCV expects all employees to respond and participate to emergency situation per emergency policies and procedures.



  • 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.
  • Working knowledge of 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.
  • Knowledge or trainable in using relational database and Excel spreadsheets


  • Bi-lingual in English and API language or Spanish
  • Prior experience working with homeless, substance using or chronically mentally ill individuals.

Apply online here.