ECM Lead Care Manager

Whole Person Care Clinic•Santa Ana, CA

7h•Onsite

About The Position

National Healthcare & Housing Advisors (NHHA) is creating this role to support the coordination, oversight, and delivery of Enhanced Care Management (ECM) services for members with complex medical, behavioral health, and social needs. The ECM Lead Care Manager provides direct care management while guiding day-to-day care coordination activities, supporting Lead Care Managers and care team members, and ensuring services align with program requirements, established workflows, and whole-person care principles. The role oversees member engagement, comprehensive assessments, individualized care plans, care transitions, and coordination with healthcare providers, community-based organizations, and social service resources. It monitors caseload activity, documentation quality, service delivery, and program performance while providing guidance, coaching, and support to care management staff. The position also identifies barriers to member engagement, service access, and continuity of care, ensuring concerns are addressed and escalated appropriately. The position calls for leadership, communication, organization, and care coordination skills, with a commitment to person-centered service delivery, interdisciplinary collaboration, accurate documentation, and improving health outcomes for individuals with complex healthcare and social support needs. Work is primarily on-site in a shared clinic or residential care environment, with travel to partner sites, client homes, and meeting places.

Requirements

Medical background with appropriate training and oversight.
Knowledge of medical terminology and client care practices.
Excellent verbal and interpersonal communication skills.
Strong organizational skills for coordinating care between clients and their care team.
Ability to work independently and make decisions in a fast-paced environment.
Proficiency in care coordination.
Experience with electronic health record (EHR) systems.
Cultural responsiveness and trauma-informed care.
Professional communication and interpersonal skills.
Time-management and organizational ability.
Basic computer literacy, including Microsoft Office and EHRs.
Confidentiality and compliance awareness.

Responsibilities

Coordinate with individuals and entities to ensure seamless client experiences and avoid duplication of services.
Conduct outreach to clients for ECM services and provide care coordination as needed, offering services where clients live, seek care, or can most easily access them, in accordance with applicable health care plan guidelines.
Connect clients with needed social and support services, including transportation.
Develop and oversee comprehensive care plans addressing clients’ medical, mental health, and social needs.
Coordinate and advocate for clients with healthcare providers, social services, and community resources to support seamless care transitions and continuous support.
Conduct regular assessments of client progress and adjust care plans as needed.
Monitor client care outcomes and implement quality improvement initiatives to enhance service delivery.
Accompany clients to office visits as needed and according to health care plan guidelines.
Monitor client treatment adherence, including medication adherence.
Use motivational interviewing, trauma-informed care, and harm-reduction approaches.
Provide health promotion and self-management training.
Build relationships with healthcare providers, community organizations, and other stakeholders to support collaborative care.
Act as a liaison among clients, families, and healthcare teams to facilitate communication and client advocacy.
Participate in multidisciplinary team meetings and case conferences to discuss client care and coordinate services.
Identify opportunities for program development and implement care management strategies to improve client outcomes.
Guide day-to-day care coordination activities and support, coach, and provide guidance to Lead Care Managers and care team members.
Monitor caseload activity, documentation quality, service delivery, and program performance.
Identify barriers to client engagement, service access, and continuity of care, and ensure concerns are addressed and escalated appropriately.