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Job Title: Outreach/Engagement/Patient Care Coordinator.

Organization: Zoya ECM (Enhanced Care Management) Provider.

Location: Remote/hybrid/Community-Based.

Office: Address:

Main Office: 1900 Powell St, Emeryville, CA.
North Bay: 1320 Gateway Blvd, Fairfield, CA.
South Bay: 2000 The Alameda, San Jose, CA.

Employment Type: Full-Time or Part-Time (as determined by program needs).

Pay: $23.00 - $25.00 per hour.

About Zoya ECM Provider:
Zoya Care Provider is a community-based organization delivering Health Home Care Coordination services to individuals with complex medical, behavioral health, and social service needs. Zoya ECM Provider serves underserved and high-risk populations by improving access to healthcare, housing, behavioral health services, and community resources through person-centered, trauma-informed, and culturally responsive care.

Position Summary:
The Outreach Coordinator plays a critical role in identifying, engaging, and enrolling eligible individuals into Zoya ECM program. This position focuses on community outreach, client engagement, education about the ECM program, scheduling, and coordination support. The Outreach Coordinator conducts outreach through phone calls, mailings, hospital alerts, and location research; educates individuals about Health Home services; and coordinates timely connections with care coordinators. This role also supports hospital transition planning, including daily monitoring of hospital alerts and coordination of post-discharge follow-up visits. All duties must be performed in compliance with Zoya ECM Care Provider policies and procedures, HIPAA regulations, and ECM program requirements.

Key Responsibilities:

Outreach and Engagement Responsibilities:
Outreach & Member Identification:

Conduct outreach to potential and existing members via phone, mail, and in-person contact, including homes, shelters, clinics, hospitals, and other approved community locations.
Identify and engage individuals who are eligible for ECM services.
Complete a minimum of three (3) outreach attempts per client per month in compliance with Health Home standards.

Member Engagement & Relationship Building:

Establish rapport and build trust using a trauma-informed, culturally responsive, and person-centered approach.
Contact and welcome newly assigned members in a timely manner.
Explain program services, benefits, expectations, and available support.
Educate members on their rights and responsibilities within the program.

Client Education & Enrollment Support:

Educate clients and referral partners about Zoya ECM Provider services and the Health Home program.
Schedule appointments for enrollment, intake, and follow-up visits with Care Coordinators (in-person, telehealth, or phone based on member preference).
Provide appointment reminders and document all reminder attempts in accordance with agency policy.

Care Coordination Support

Schedule medical, behavioral health, and care coordination appointments.
Arrange transportation services as needed to support appointment attendance.
Monitor hospital alert systems daily.
Notify Care Coordinators of hospital admissions, emergency department visits, and discharges in a timely manner.
Coordinate hospital visits and ensure post-discharge follow-up, including home or community visits as required.
Facilitate warm handoffs between members and Care Coordinators.
Support Care Coordinators with ongoing member follow-up activities.

Monitoring and Documentation:

Document all outreach activities, member interactions, and care coordination efforts accurately and in a timely manner in the designated electronic record system.
Maintain complete and compliant documentation of appointment reminders and outreach attempts.
Monitor hospital admissions and emergency room alerts to support continuity of care.

Reporting & Tracking Requirements:

Prepare, maintain, and submit required tracking tools, including: Opt-out client tracking spreadsheet (submit to supervisor as required).
Hospital discharge tracking spreadsheet (submit to supervisor as required).
Resource and referral tracking logs to support care coordination.
Submit weekly or daily schedules to Care Coordinators at least one (1) day prior to scheduled client visits.

Member Support & Retention:

Assist members in remaining engaged with their individualized care plans.
Identify and address barriers to care, including: Transportation challenges.
Access to services.
Communication barriers.
Social determinants of health.
Provide ongoing support to improve adherence to care and overall health outcomes.

Collaboration & Communication:

Respond promptly to emails and phone calls from community partners, referral sources, and internal team members.
Maintain professional relationships with healthcare providers, hospitals, community agencies, and social service organizations.
Participate in team meetings, training, supervision, and quality improvement activities.

Compliance & Professional Standards:

Maintain strict client confidentiality and comply with HIPAA and Zoya ECM Provider policies.
Always follow professional boundaries and ethical standards.
Adherent to safety protocols during community-based outreach.
Perform other duties as assigned to support program goals.

Qualifications:

Required Qualifications:

High school diploma or equivalent.
Experience in outreach, community health, social services, or a related field.
Strong verbal and written communication skills.
Ability to work independently, remain organized, and manage time effectively.
Cultural humility and experience working with diverse populations.
Basic computer skills, including documentation and spreadsheet tracking.
Ability to meet Health Home outreach and documentation requirements.

Preferred Qualifications:

Experience working with Medicaid populations, Health Home programs, or care coordination services.
Knowledge of community resources related to healthcare, housing, behavioral health, and social services.
Multilingual skills (preferred but not required).
Background in public health, social work, human services, or related fields.

Skills & Competencies:

Client engagement and relationship-building.
Organization, scheduling, and time management.
Problem-solving and community resource navigation.
Ability to schedule medical, dental, and mental health appointments for clients.
Professional judgment and ethical practice.
Trauma-informed, person-centered care delivery.
Team collaboration and communication.

Work Environment:

This position is primarily remote/hybrid and community-based and requires flexibility to meet clients where they are.
Outreach may occur in a variety of settings, including homes, hospitals, shelters, and community locations.
Adherence to safety guidelines, professionalism, and organizational policies is required.

How to Apply:

Interested candidates should submit a resume and cover letter to Zoyacareprovider@gmail.com.
Qualified applicants will be contacted for an interview.

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