ECM Case Manager - LCSW/LMFT (Inland Empire Region)

Astrana Health, Inc.•Monterey Park, CA

3d•$34 - $41•Hybrid

About The Position

The ECM Case Manager (LCSW or LMFT) provides clinically informed care management, under the supervision and direction of the Manager, Strategy & Operations and RN Clinical Consultant, to a caseload of high-need Medi-Cal members enrolled in Astrana Health’s Enhanced Care Management (ECM) program. The role supports members with chronic health conditions, behavioral health needs, substance use disorders, homelessness, or frequent hospitalizations by coordinating care, closing gaps in services, and connecting members to clinical and community-based resources. The Case Manager works cross-functionally with internal teams, community-based organizations, and health plan partners to improve health outcomes, reduce health disparities, and support continuity of care, advancing the ECM program’s quality, compliance, and member engagement goals. This hybrid role is based at the Monterey Park office and includes work both in the office and at home each week. Occasional travel may be required for weekly field visits to homes and community-based settings. Working hours are Monday through Friday, between 8:30 AM and 5:00 PM. Compensation is $34.00–$41.00 per hour, with actual compensation determined by geographic location, experience, and other job-related factors.

Requirements

Graduate degree in social work or marriage and family therapy from an accredited institution (LCSW or LMFT).
At least 1 year of clinical experience in a healthcare setting, such as a skilled nursing facility, home health, hospice, case management, or care coordination.
Active, unrestricted California LCSW or LMFT license.
Ability to maintain confidentiality and discretion when handling sensitive member, provider, and business information.
Ability to work autonomously, multitask, and exercise sound clinical judgment.
Strong analytical, critical reasoning, organizational, and interpersonal communication skills.
Strong written and verbal communication skills.

Nice To Haves

Familiarity with care plan goal setting, including developing problem statements, interventions, and goals.
Ability to learn and navigate multiple case management software platforms and health plan portals while maintaining data accuracy.
Bilingual in Spanish.
Experience in a managed care environment, such as a health plan, IPA, or MSO.
Utilization Management or Hospice Case Management experience.
Working knowledge of DHCS, DMHC, NCQA, and CMS standards.

Responsibilities

Manage an assigned caseload of members with complex medical, behavioral, and social needs across multiple health plan contracts.
Conduct outreach to members regardless of case assignment or health plan to support ECM program engagement and team goals.
Meet members in person, including through home visits, provider office visits, and community-based settings, to build trust, complete assessments, review care plans, and support engagement.
Conduct member outreach and complete initial comprehensive assessments, care plans, and interdisciplinary team conferences within timeframes set by ECM leadership.
Develop member-centered care plans with clear, measurable, achievable goals, and regularly review and update goals based on member progress.
Support the RN Care Manager with clinical assessments, including comprehensive health assessments, medication reconciliation, post-hospital discharge assessments, and standardized screening tools such as PHQ-9, GAD-7, and the Edinburgh Postnatal Depression Scale.
Maintain accurate and timely documentation in case management software, Excel trackers, Monday.com boards, and health plan portals.
Coordinate transitions of care, including post-hospital and skilled nursing facility follow-up.
Communicate proactively with primary care providers, specialists, behavioral health providers, hospitals, and community-based organizations to complete referrals and prevent gaps in care during transitions.
Review claims and authorizations and perform medication reconciliation in support of care coordination.
Work with internal and external partners in a team-based approach to support ECM program success, including supporting ECM members across contracted health plans in addition to managing an individual caseload.
Connect members to social services, transportation, housing, food, and other community resources.
Use motivational interviewing, trauma-informed care, and harm-reduction approaches to support member engagement.
Identify barriers to treatment adherence and adjust care plans accordingly.
Educate members and caregivers about disease management and healthcare navigation.
Monitor member progress and caseload activity weekly, ensuring deliverables and outcomes are met.
Participate in audits, quality reviews, and team meetings as required.
Maintain accurate and honest timekeeping.
Support fellow care managers by sharing best practices and contributing to a positive, accountable team culture.
Perform other duties as assigned.