Care Coordinator

“Every person deserves compassion, dignity, and the safety of a place to call home.”

Homelessness is the largest social and public health crisis in California. Illumination Foundation (IF) is a growing non-profit organization dedicated towards disrupting the cycle of homelessness by providing targeted, interdisciplinary services in our recuperative care centers, emergency shelters, housing services and children's and family programs. IF currently has 13+ facilities with 22+ micro-communities scattered across Orange County, Los Angeles County and the Inland Empire.


Job Description 

• Serves as primary point of contact for clients
• Conducts routine health assessments related to wholistic health and changes in acuity when hospitalized
• Routinely creates and revises Care Plan goals and interventions in a SMART format
• Visit clients’ home or place of residence to promote monthly ECM Health Promotion (Health Education and Preventative Care services) initiative
• Accompany clients to medical appointments as needed
• Communicate with Care Team members (Care Coordinators, primary care physicians, and other health care providers) to facilitate client care
• Observe, report, and assess client self-administration of medication
• Connect ECM members to other social services and supports they may need, including transportation
• Coordinate with hospital staff on ECM member discharge plans
• Carries a full caseload of 45 ECM members, unless instructed otherwise by senior management within the scope of policy guidelines
• Identifies gaps in and barriers to service, documenting in the member’s care plan, and communicating these to the multidisciplinary care team to develop and implement a response
• Prepares for and participates in individual and group supervision meetings
• Provides weekly reports on progress of client engagement and billable activity. 

• Responsible for documenting all engagement and frequency of content in Illumination Foundation’s EMR in accordance with standards of practice as required by Illumination Foundation and associate contract entities. These Practices include:
• Incrementally documenting all aspects of a client care plan, including goals met as well as goals forthcoming
• Documenting level of engagement such as frequency and duration of encounters
• Documenting evaluative client case details which factor into decisions made to referral clients to alternative resources
• Documenting obtained client records, such as vitals documents, insurance cards, SSI award letters, etc.
• Documenting client disengagement as well as engagement
• Remain aware of current services offered by other services providers
• Maintain strict confidentiality in accordance with agency policies
• Track client information, schedule, files, and forms
• Track client attendance at medical appointments and patient navigation sessions and initiative outreach and missed appointment procedures, as necessary.