• Develops lists of viable referrals, makes telephone calls to support the sales process and to follow up / follow through on patient referral process, makes daily sales calls to referral sources
• Educates various members of the community on assigned services provided by Senior Living Partners.
• Provides a weekly planning calendar to the Director of home health and the CEO that includes all activities and appointments.
• Submits reports to the Director of Home Health and CEO on contacts made and the outcome of all meetings.
• Uses CRM tracking software and participates in regular team meetings.
• Establishes viable relationships with accounts served and tracks admissions from referral sources.
• Follows up on referrals and gives feedback to referral sources and clinical staff.
• Receives patient information from physicians, hospitals, clinics, and other agencies. 
• Documents patient information and orders/instructions for care and submits to appropriate nursing supervisors and caregivers.
• Proactively collaborates with clinical staff to ensure Senior Living Partners can meet the client needs before admission.
• Develops and maintains relationships with businesses, organizations, and related associations to promote Senior Living Partners.
• Arranges for special medical supplies or appliances, developing a network of resources that also may be potential referral sources.
• Supports continuity of patient care with minimal interruption in treatment routines.

Skills: Sales Process Management, Community Education, Weekly Activity Planning, Reporting and Documentation, CRM Proficiency and Team Collaboration, Relationship Building with Accounts, Referral Follow-Up and Feedback, Patient Information Management

• Involves clients and family members in planning the transition from other care providers and methods to the delivery of health care services in the home.
• Brings appropriate issues and problems to the attention of the CEO, Director of Home Health, and other leaders to improve and enhance services rendered.
• Explains agency policies to clients and family members including Patient’s Rights and Responsibilities, with special emphasis on reducing anxiety and assisting those affected with lifestyle adjustments. 
• Plans and facilitates various meetings and group presentations.
• Attends professional organization events and networking functions.
• Attends and/or sponsors health fairs, trade shows, community events, and other functions that lead to new business prospects and referral development.
• Develops and implements comprehensive marketing plans in collaboration with the CEO, Director of HOME HEALTH, and Clinical Supervisors to meet census goals.
• Establishes and maintains relationships with hospital professionals to enable effective and efficient referrals to services. 
• Communicate with hospital and Senior Living team members to provide education, share information, and establish collaboration. 
• Serves as a liaison and communicator between hospital staff and Senior Living and the Home Healthcare team members.
• Develops positive and professional relationships with potential patients and caregivers/family members to provide information and education regarding services available through Senior Living Partners Home Health. 
• Identifies health care needs in partnership with clients, families, and health care providers to ensure appropriate service levels are provided. 

Skills: Client and Family Engagement, Problem Escalation and Reporting, Policy Communication, Meeting and Presentation Facilitation, Professional Networking and Event Participation, Marketing Strategy Development, Relationship Building with Healthcare Professionals, Liaison and Communication Coordination.

• Enables smooth and efficient transfers between acute services and Senior Living Partners. 
• Promotes confidence in services and ensures patients and families' physical and psycho-social needs are met during the transfer process.
• Follows processes to ensure efficient and customer-focused transitions between acute care settings to Home Health services. 
• Ensure clients’ and families’ individualized needs are met including facilitating transportation or other concierge services.
• Coordinates services with contracted vendors, outside agencies, and interdisciplinary teams. 
• Ensures a timely schedule of referral and admission visits. 
• Complete admission visits by the Director of Home Health and complete paperwork and tasks associated with admission visits.
• Meets or exceeds monthly goals, growth and development targets and actively establishes and maintains market awareness.
• Establishes and maintains professional relationships with referral sources and decision-makers, including physicians, nursing homes, assisted living facilities and hospital personnel, including case managers, discharge planners, long-term care facilities and other appropriate referral sources and community organizations. 
• Tracks admissions from each referral source.
• Provides account management and weekly reporting, including a weekly sales planning calendar and outcome reports.

Skills: Service Transition Management, Patient and Family Support, Process Adherence for Transitions, Individualized Needs Coordination, Vendor and Team Coordination, Timely Referral and Admission Scheduling, Admission Process Management, Relationship Building and Market Awareness.

• Plans and implements a methodology of follow up on all referrals, giving feedback to both the referral source and clinical staff.
• Receives patient information from physicians, hospitals, clinics, and other agencies. 
• Documents patient information, along with all orders/instructions for care and submits to appropriate nursing supervisors and caregivers. 
• Assures Senior Living Partners Home Health can meet the client’s needs prior to admission。
• Meets with patients and family members to discuss and assess hospice eligibility.
• Responsible for community outreach and the development of relationships with community businesses, organizations, and related associations to promote Senior Living Partners.
• Plan, create, and implement sales plan and strategies – including direct mail, public and media relations, and event marketing/presentations.
• Initiates the referral intake process and coordinates admissions with appropriate team members and facility staff when applicable.
• Attends and participates in Case conferences and Interdisciplinary team meetings.
• Acts as a liaison with staff regarding patients, communicating admission, discharge, and any other applicable information to the appropriate team.
• Involves the patient/client and family members in planning the transition from other care providers and methods to the delivery of health care services in the home.
• Brings appropriate issues and problems to the attention of the Director of Home Health to improve and enhance services rendered.
• Explains agency policies to patient/client and responsible family members, including Patient’s Rights and Responsibilities, with special emphasis on reducing anxiety and assisting those affected with lifestyle adjustments.

Skills: Patient Care Coordination, Documentation and Record Keeping, Community Outreach and Relationship Building, Sales and Marketing, Admissions Coordination, Team Collaboration and Communication, Patient and Family Education, Problem Solving and Initiative

• Participate in initial and ongoing training about common issues in neurodegenerative diseases, aging, caregiving, advance care planning, and medication management.
• Maintain regular monthly telephone (or e-mail) contact with a caseload of 60-80 participants.
• Follow care protocols to complete baseline and annual care plans that meet quality standards.
• Attend weekly debriefing sessions with the clinical team to review cases and discuss issues, problem-solving strategies, resource needs, and communication techniques.
• Attend weekly check-in meetings with clinical staff at clinic site to discuss workflows, identify referrals and clarify needs and action items.
• Use standard templates to document care delivery, including time spent on each encounter, in electronic medical records.
• Input data into REDCap for quality monitoring, caseload management, and research purposes.
• Participate in evaluation and improvement by contributing feedback during team meetings, surveys, and one-on-one meetings with the supervisor.
• Assist with on-demand training webinar development by providing input on webinar content, assisting with formatting PowerPoint presentations, helping with basic video editing, and scheduling meetings.
• Assist with scheduling and coordinating caregiver training workshops hosted by the UCSF Care Ecosystem team.

Skills: Caseload Management, Care Planning and Protocols, Team Collaboration and Communication, Documentation and Record Keeping, Evaluation and Feedback, Training Development Support, Workshop Coordination

• Experience in medical, mental health and/or behavioral healthcare, social work, community outreach, or patient advocacy
• Having LCSW, LCPC, LPCC, LMFT
• Must be able and comfortable with maintaining metrics and goals within the department
• Comfortable working telephonically and with computer systems while assisting members
• Comfortable making outreach to members without prior engagement
• Excellent verbal/written communication skills
• Ability to work in a team environment.
• Flexibility and strong organizational skills needed.
• Must be proficient in MS Office and internet/web navigation
• Experience in medical, mental health and/or behavioral healthcare, social work, community outreach, or patient advocacy
• Strong understanding of cultural competency with the working population
• Experience with commercial health plans 
• Strong Bi-lingual (English/Spanish)

Qualifications: BA in Healthcare Administration with 5 years of Experience

• Previous experience in the medical field preferred
• Demonstrated ability to work collaboratively within a team environment
• Exceptional customer service and interpersonal skills
• Strong verbal/written communication and organizational skills to effectively communicate with patients and matrix partners
• Proven administrative abilities, with strong computer and software application skills
• Medical terminology preferred
• Ability to convey information to customers in a warm, clear, concise manner
• Demonstrates positive customer service behaviors
• Ability to excel at details, multi-tasking and working under pressure
• Experience in a Care Navigation/Coordination role within a healthcare environment, preferably mental health
• Excellent verbal and written communication
• Detail-oriented and impeccable organizational skills are a must.
• Self-starter, willing to roll up sleeves and be proactive and solution-oriented.
• Nimble and open to frequent change, iterative processes, and operating in a testing culture.
• Willingness to understand the mental health industry in order to guide learning and ensure success in the role.
• Must be legally authorized to work in the United States without the need for employer sponsorship now or anytime in the future.

Qualifications: BA in Social Work with 4 years of Experience

• Basic Life Support (BLS) certification
• Experience working with community programs and services preferred.
• Experience in a health/human services environment preferred.
• Excellent written and oral communication skills.
• Ability to work independently with little supervision and work on multiple projects.
• Experience working with culturally and economically diverse populations.
• Knowledge of medical systems and community resources.
• Strong interpersonal skills including professional telephone skills and the ability to work with medical and support staff in a professional manner.
• Proficient with Microsoft Office applications including Word and Excel
• Ability to obtain ACM or CCM certification from date of hire.
• Knowledge of guidelines and regulations relevant to care management and utilization management
• Ability to develop a thorough, comprehensive plan of care, to include options and goals, in collaboration with care team and patient
• Ability to act as an advocate for the patient to assure quality of care and attainment of appropriate goals
• Ability to access and interpret data, utilizing findings in determining plans of care.

Qualifications: BS in Nursing with 5 years of Experience

• Experience in a healthcare-related field 
• Experience (e.g. EMT, health educator, community health worker, social worker, health plan, medical corps and clinical office. staff.)
• Strong skills in comprehending and assess patient's grievances to quickly locate appropriate resources for assistance. 
• In-depth knowledge of the organization and how to get issues resolved.
• Strong interpersonal and customer service skills. 
• Ability to communicate and resolve issues effectively with a diverse population of patients, staff and physicians.
• Excellent analytical and problem-solving skills. 
• Ability to develop solutions and recommend changes and follow through with implementation.
• Excellent written and verbal communication skills.
• Work independently in a fast-paced, demanding environment with minimal supervision.

Qualifications: BA in Psychology with 2 years of Experience

• Ability to manage and oversee multiple tasks simultaneously, including high daily call volume
• Knowledge of medical terminology.
• Prior experience developing work flow procedures and implementing systems to improve operations.
• Proficiency with EPIC APeX applications.
• Interest and/or experience working with older adults who may have cognitive difficulties.
• Proficiency with Windows-based software including Microsoft word, Excel, Outlook. 
• Knowledge of computer systems and software used in functional area.
• Strong knowledge of Patient Rights & Responsibilities, Joint Commission standards, and Centers for Medicare / Medicaid regulations. 
• Knowledge of Medical Terminology. 
• Strong knowledge of data collection, compilation, and analytical techniques.

Qualifications: BS in Public Health with 4 years of Experience