Care Coordinator - Enhanced Care Management (ECM) (3602)

MERCY HOUSE•Santa Ana, CA

4d•$23 - $24

About The Position

The Enhanced Care Management (ECM) Lead Care Manager is responsible for coordinating medical and non-medical supportive services to meet the needs of each member. These services include physical, behavioral, dental, developmental, oral health, long-term services and supports (LTSS), Specialty Mental Health Services, Drug Medi-Cal/Drug Medi-Cal Organized Delivery System programs, Community Supports, and other resources addressing social determinants of health (SDOH)—regardless of the care setting. The ECM Lead Care Manager collaborates closely with the CalAIM Community Supports Program to deliver team-based, patient-centered care for clients experiencing or at risk of homelessness.

Requirements

Bachelor’s Degree in Social Work (or related field) with experience working in recovery, mental health, and co-occurring disorders are preferred
Candidates without a BA/BS degree but with at least 2 years of relevant experience working with individuals experiencing long-term homelessness, low-income backgrounds, and diverse populations, and who possess a working knowledge of mental health and substance use issues, are encouraged to apply
A minimum of 1 year of experience in care coordination or case management is strongly preferred, particularly with the following populations: Individuals or families experiencing homelessness High utilizers of hospital or emergency services Individuals with serious mental illness (SMI) and/or substance use disorders (SUD) Adults transitioning from nursing facilities to community-based settings Adults with intellectual or developmental disabilities
A valid CA driver’s license, proof of insurance and a reliable vehicle is required. Comfortable with utilizing your own vehicle to conduct home visits, visiting clients at shelters, meeting clients out in the community etc.
Ability to work effectively with a diverse population; plan, organize and prioritize duties; crisis intervention as needed; clearly communicate information and instructions verbally and in written form; maintain a positive, professional, and safe environment while on duty; and establish and maintain effective working relationships with others
Dependability, responsibility, and the ability to communicate effectively and respectfully are mandatory skills
Computer literacy and proficiency in Microsoft Office programs (Word, Excel, Outlook, PowerPoint) are required

Nice To Haves

Preferred skills include outreach and engagement, care planning, care coordination, health promotion, transitional care support, member and family education, and linkage to social services
Experience with HMIS Data Entry/CalOptima Health is highly preferred
Preferred experience with Housing First and harm reduction models, Motivational Interviewing, Patient-Centered and Trauma-Informed Care, Crisis Intervention and Prevention strategies
Experience assisting individuals and families with complex needs (acute mental illness and substance use) to access healthcare and community resources is highly preferred
Fluency in Spanish is of significant value

Responsibilities

Manage a caseload of approximately 17–25 members, meeting regularly to complete Health Needs Assessments and develop individualized Care Plans with measurable short- and long-term goals
Conduct outreach, engage, and enroll eligible members in ECM services, addressing barriers to access and care
Provide services at locations that are accessible and convenient for the member, including their residence or places where they seek care, in alignment with CalOptima Health guidelines
Assist members with care engagement, including medication reconciliation, scheduling and reminding about appointments, coordinating transportation, and attending critical medical visits when needed
Advocate on behalf of members with healthcare providers and assist with hospital discharge planning
Coordinate care with hospitals, behavioral health providers, specialists, dental providers, LTSS entities, and Community Supports partners
Utilize trauma-informed care and motivational interviewing techniques to engage members
Monitor treatment adherence, including medication compliance
Provide health education, self-management support, and care navigation to empower members
Regularly communicate member updates, needs, and concerns to the multidisciplinary care team to enhance care outcomes
Perform additional duties as assigned or modified to support program goals
Collaborate as a team member within Mercy House, supporting the organization’s mission and core values
Participate in internal and external meetings and contribute to planning resident-focused programs
Maintain adaptability in a fast-paced, team-based environment while demonstrating empathy, reliability, and effective communication with diverse populations
Maintain thorough and timely documentation for all assigned members, including Health Needs Assessments and Care Plans
Support data collection and reporting requirements
Ensure timely completion of all assigned tasks and meet documentation deadlines
Utilize technology and software tools proficiently (e.g., Microsoft Word, Outlook, Excel, PowerPoint), along with any position-specific systems
Respond to emails and phone inquiries promptly and manage workload independently while prioritizing responsibilities