Description

Principal Duties, Expectations, and Responsibilities 

Oversee care coordination for high-need members enrolled in Medi-Cal managed care. Enhanced Care Management (ECM) services focus on a whole-person approach to supporting children and adults facing complex medical, behavioral, and psychosocial challenges, aiming to reduce preventable hospital and emergency department admissions. The role includes outreach, screening, intensive case management, care plan development, and linking members to medical, psychiatric, social, educational, and other services as needed. The following statements for this position reflect only some specific responsibilities and are considered necessary to describe the principal functions of the job as identified and shall not be considered a detailed description of all duties required that may be inherent in the position:

• Conducting on-site and field-based visits to enroll individuals in ECM and provide services.
• Outreaching and engaging community individuals who are underserved to enroll in ECM services.
• Serving as the primary contact to enrolled ECM members and advocating to help them navigate the healthcare system.
• Conducting initial screening, assessments, and reassessments to identify health, behavioral, and social needs of the enrolled members.
• Completing care planning in collaboration with the member to develop a patient-centered care plan.
• Providing intensive case management to ensure linkages to medical, psychiatric, social, educational, and other services as needed.
• Consulting with members’ primary care provider, specialists, behavioral health providers, family members, and other support individuals for optimal care plan progress.
• Monitoring implementation of the care plan and making updates as necessary to accomplish the member’s goals.
• Educating members on self-management skills and supporting health behavior change utilizing motivational interviewing, trauma informed care, and harm-reduction approaches 
• Ensuring that Enhanced Care Management (ECM) strategies and services are whole-person centered, linguistically, and culturally appropriate.
• Completing data collection, reports, and other documentation to ensure accuracy of member data, enrollment, services, progress, and transition of care.
• Monitoring and evaluating the effectiveness and efficiency of programmatic service delivery.
• Contract compliance activities including meeting the contract objectives, documentation requirements, evaluation activities, and other performance related issues.
• Establishing and maintaining liaison with community organizations, local entities, and community stakeholders for outreach and engagement.
• Assist in developing outreach activities to reach participants who are under-resourced and/or underserved.
• Responsible for maintaining and updating a comprehensive list of available resources for patients, ensuring accurate and timely access to essential services.
• Identifying and locating relevant resources to meet patient needs and ensuring the resource database is current and easily accessible.
• Adhere to HIPAA regulations and other relevant laws to protect patient privacy and confidentiality in all communications.
• Attend relevant meetings, trainings, events, and activities.
• Perform other duties as assigned by the executive leadership and administration.

Requirements

Education, Certification, and Experience Requirements

• High school diploma or equivalent
• 1 year of experience in care coordinating
• Experience working with common health care programs, preferred
• Experience working with underserved and diverse populations, preferred
• Basic knowledge of medical terminology, preferred
• Electronic Health Record (EHR) experience, preferred