Care Coordinator

• Develops, assesses, and coordinates holistic care management activities for long-term care members
• Develops or assists with personalized service care plans and educates members and caregivers on available services and benefits
• Evaluates member needs and available resources and recommends or facilitates appropriate care plans
• Identifies providers, specialists, and community resources for long-term care
• Coordinates members, caregivers, and care provider teams to ensure services are accessible
• Provides resource support for employment, housing, participant direction, independent living, justice, and foster care needs
• Monitors care plans, member status, and outcomes and recommends updates based on member needs
• Interacts with long-term care providers and partners
• Collects, documents, and maintains member information and care management activities for regulatory compliance
• May conduct on-site visits to assess member needs and collaborate with providers or resources
• Educates members and caregivers on procedures, provider instructions, service options, referrals, and healthcare benefits
• Provides leadership feedback on opportunities to improve quality of care and cost-effective service delivery
• Performs other assigned duties

LTSS Service Care Coordinator

• Conduct monthly CCM phone calls with the assigned practice
• Complete required patient interactions to meet CCM service goals
• Educate patients on chronic conditions and care plans
• Coordinate care with provider offices, pharmacies, and community resources
• Identify gaps in care and social determinants of health
• Create and update personalized care plans in the EMR
• Accurately document all patient interactions
• Maintain HIPAA compliance and patient confidentiality
• Spend most of the workday on the phone speaking with patients, coordinating care, and documenting interactions
• Meet daily productivity metrics in a structured remote environment

Part-Time Care Coordinator

• Conduct monthly Chronic Care Management phone calls with the assigned practice
• Make 30–50 outbound calls per day
• Complete required patient interactions to meet CCM service goals
• Educate patients on chronic conditions and care plans
• Coordinate care with provider offices, pharmacies, and community resources
• Identify gaps in care and social determinants of health
• Create and update personalized care plans in the EMR
• Accurately document all patient interactions
• Maintain HIPAA compliance and patient confidentiality
• Work a fixed schedule Monday–Saturday, 9:30 AM–6:00 PM in the supported time zone
• Spend 7–8 hours per day on the phone while meeting monitored productivity and quality metrics

• Conduct structured intake appointments with new patients to collect information relevant to the bio-psycho-social evaluation process
• Gather and document demographic information, presenting concerns, psychosocial background, family and social history, educational and occupational history, prior behavioral health treatment, current medications, and basic health history
• Document collected information accurately in the electronic medical record (EMR) to assist licensed providers in completing clinical evaluations
• Work collaboratively with licensed clinicians to support the intake and evaluation process
• Ensure relevant patient history and intake information are available for provider review
• Communicate pertinent information gathered during intake to appropriate clinical staff
• Schedule and coordinate initial evaluation appointments with appropriate providers
• Ensure required intake forms, questionnaires, and consent documentation are completed before evaluation appointments
• Verify patient demographic and insurance information
• Upload, organize, and maintain patient documentation within the EMR
• Ensure intake records are completed in a timely manner
• Provide a welcoming and supportive experience for patients entering care
• Answer basic questions regarding services, scheduling, and intake procedures
• Escalate urgent concerns or clinical issues to licensed providers or clinical leadership
• Adhere to HIPAA and patient confidentiality requirements and follow organizational policies

• Manage a caseload of approximately 60–70 members
• Coordinate care across medical, behavioral health, and community services
• Document in real time or by end of day using internal systems
• Develop and manage individualized care plans
• Coordinate appointments, services, and follow-ups across providers
• Support transitions of care, including hospital discharges and referrals
• Build trust through consistent, in-person engagement
• Advocate for timely access to care, services, and resources
• Support members navigating housing, food access, transportation, and behavioral health needs
• Represent Pacific Health Group through community outreach events, partnerships, and local initiatives
• Build and maintain relationships with community-based organizations, shelters, and local resource partners
• Identify opportunities to expand community presence and improve member access to services
• Connect members to local programs and services
• Identify gaps in resources and escalate when needed
• Complete timely and accurate documentation
• Maintain compliance with Medi-Cal, CalAIM, and ECM program requirements
• Provide administrative support across Pacific Health Group
• Support coordination between departments and business units and assist department managers with ongoing tasks and cross-functional priorities
• Represent Pacific Health Group and its affiliates professionally with staff, visitors, vendors, partners, and community stakeholders
• Perform accurate data entry and maintain company databases, tracking systems, and internal platforms
• Organize and manage electronic files securely and according to company standards
• Prepare reports, spreadsheets, and presentations
• Partner with internal teams, providers, and community stakeholders
• Participate in case conferences and care coordination meetings

Enhanced Care Management Lead Care Coordinator

• Create, plan, organize, lead, and facilitate child and family team meetings
• Provide care coordination in families' homes, communities, or preferred locations
• Partner with youth, families, natural supports, and service providers to identify needs and services
• Ensure youth and families have voice and choice in coordinated care and services
• Maintain documentation to access and maintain OhioRISE benefits
• Meet ISBH OhioRISE quality and fidelity requirements
• Acquire and maintain knowledge of community resources
• Attend mandatory in-person and virtual trainings and supervision, with required travel
• Complete assigned trainings and maintain required certifications
• Follow ISBH policies and procedures regarding confidentiality, professionalism, and incident reporting
• Use databases and Electronic Health Record systems for accurate client documentation
• Maintain compliance with HIPAA, mandated reporting requirements, and professional ethical guidelines
• Travel within the assigned service area
• Perform other duties as assigned

• Create, plan, and organize a team defined by the family
• Develop, lead, and facilitate child and family team meetings
• Provide care coordination in families' homes, communities, or preferred locations
• Partner with youth, families, natural supports, and service providers to identify needs and services
• Ensure youth and families have voice and choice in coordinated care and services
• Maintain documentation to access and maintain OhioRISE benefits
• Meet ISBH OhioRISE quality and fidelity requirements
• Maintain knowledge of community resources
• Attend mandatory in-person and virtual trainings and supervisions, including travel
• Complete assigned trainings and maintain required certifications
• Follow confidentiality, professionalism, and incident-reporting policies
• Use databases and Electronic Health Record systems for client documentation
• Maintain HIPAA, mandated reporting, and professional ethical compliance
• Travel within the assigned service area
• Perform other duties as assigned

• Create, plan, and organize a team as defined by the family
• Develop, lead, and facilitate child and family team meetings
• Provide care coordination in the family’s home, community, or preferred location
• Partner with youth, families, natural supports, and service providers to identify care coordination needs and services
• Ensure youth and families have voice and choice in coordinated care and services
• Maintain documentation required to access and maintain OhioRISE benefits
• Meet ISBH OhioRISE quality and fidelity requirements
• Maintain knowledge of community resources
• Attend mandatory trainings and supervisions
• Complete assigned trainings and maintain required certifications
• Follow confidentiality, professionalism, incident reporting, HIPAA, mandated reporting, and ethical requirements
• Use databases and Electronic Health Record systems for client documentation
• Travel within the assigned service area
• Perform other duties as assigned

• Create, plan, organize, lead, and facilitate child and family team meetings
• Provide care coordination in families' homes, communities, or preferred locations
• Partner with youth, families, natural supports, and service providers to identify care coordination needs and services
• Support youth at home, in school, and in their communities
• Help keep families together and reduce hospitalizations
• Ensure youth and families have voice and choice in coordinated care and services
• Maintain documentation required to access and maintain OhioRISE benefits
• Meet ISBH OhioRISE quality and fidelity standards
• Maintain knowledge of community resources
• Attend mandatory in-person and virtual trainings and supervision, including required travel
• Complete assigned trainings and maintain required certifications
• Follow confidentiality, professionalism, incident reporting, HIPAA, mandated reporting, and ethical requirements
• Use databases and Electronic Health Record systems for client documentation
• Travel within the assigned service area
• Perform other duties as assigned

• Create, plan, organize, lead, and facilitate child and family team meetings
• Provide care coordination in families' homes, communities, or preferred locations
• Support youth at home, in school, and in their communities
• Partner with youth, families, natural supports, service providers, and community partners
• Identify care coordination needs, goals, and action steps
• Ensure youth and families have voice and choice in coordinated care and services
• Maintain documentation required to access and maintain OhioRISE benefits
• Meet ISBH OhioRISE quality and fidelity requirements
• Maintain knowledge of community resources
• Attend mandatory in-person and virtual trainings and supervision, including travel
• Complete assigned trainings and maintain required certifications
• Follow confidentiality, professionalism, incident-reporting, HIPAA, mandated-reporting, and ethical requirements
• Use databases and Electronic Health Record systems for client documentation
• Travel within the assigned service area
• Perform other duties as assigned