ECM - Lead Care Manager

San Diego Community Health Center•San Diego, CA

About The Position

Summary: The Lead Care Manager for the Enhanced Care Management (ECM) program plays a critical role in improving health outcomes for Medi-Cal members with complex medical and social needs. This position is responsible for providing comprehensive, member-centered care coordination and case management services that address the clinical, behavioral, and social drivers of health. The Lead Care Manager collaborates closely with internal providers, external partners, and community-based organizations to ensure continuity of care and effective resource utilization. Essential Duties and Responsibilities: Primary Functions: Coordinate with clinical staff to conduct comprehensive health assessments, including medical, behavioral, functional, and social determinants of health (SDOH), for each assigned ECM member. Coordinate with clinical staff to Develop, implement, and update individualized care plans that reflect member goals, needs, and measurable outcomes, ensuring alignment with HRSA core clinical performance measures (e.g., diabetes, hypertension, depression screening). Coordinate care across primary care, behavioral health, dental, substance use, housing, and specialty systems to address whole-person health needs in accordance with HRSA’s integrated services modelTrack and follow up on referrals to specialty care, housing services, substance use treatment, behavioral health, and other wraparound supports. Coordinate multidisciplinary team meetings and case conferences with providers, behavioral health clinicians, community health workers, and social services Document all case management interactions and interventions in the EHR and ECM tracking system within required timeframes. Collaborate with the Managed Care Plan’s ECM team and CalAIM stakeholders as needed to ensure program compliance and alignment. Identify and resolve barriers to care, including access to transportation, medication adherence, or cultural/language needs. Participate in population health initiatives, quality improvement activities, and care team huddles to enhance patient outcomes and operational effectiveness Monitor high-risk member panels using risk stratification tools and provide appropriate intensity of services based on member acuity. Provide patient navigation support, health system education, and linkage to resources. Maintain current knowledge of ECM program requirements, Medi-Cal managed care benefits, and community resources. Collaborate with CHW’s and Navigators as part of the care team. Maintain complete, timely, and compliant documentation for all services provided, supporting HRSA grant deliverables, compliance monitoring, and managed care ECM reporting Respond to crises and escalating needs with urgency, de-escalation skills, and coordination with emergency or behavioral health resources. Participate in the annual Uniform Data System (UDS) data collection process, contributing relevant case management and clinical coordination data. Maintain confidentiality and comply with all HIPAA regulations and ECM program data-sharing requirements.Active involvement in the community to educate about risk factors for chronic disease, increase community-based screening methodologies, and recruit newly diagnosed individuals to SDAIHC for treatment and management. Assist with program evaluation, including performance measurement, member satisfaction surveys, and continuous quality improvement related to HRSA funding expectations and ECM contractual obligations Adhere to organizational and departmental policies and procedures. Perform the clinical and administrative duties necessary to meet the goals and objectives of the grant. Maintain 50 patient case load after 6 months Other duties as assigned.

Requirements

Bachelor’s degree in social work, public health, psychology, or related field or equivalent experience in care coordination/ case management.
Ability to view the patient as a whole person within the context of their family and community.
Excellent interpersonal and communication skills.
Computer and analytic skills to run reports and review data.
Minimum of 2 years of experience, preferably in community health, case management, or care coordination
Must be a team player and be willing to put the needs of the patients first.
Understand requirements for Patient Centered Medical Home.
Experience working with vulnerable populations (e.g., individuals with SMI/SUD, homelessness, complex medical needs)
Strong knowledge of Medi-Cal benefits, community resources, and health care delivery systems.
Valid driver’s license and reliable transportation for community-based visits
CPR/ BLS certification: Maintain a current Basic Life Support (BLS) certification issued by the American Heart Association (AHA), the American Red Cross, or an equivalent organization. Certification must include an in-person, hands-on skills assessment. Online-only certifications are not accepted.
Annual background checks: Consent to annual background checks as a condition of continued employment, to ensure compliance with organizational standards and eligibility requirements.
For-Cause Drug Screening: Comply with drug screening requirements when initiated by the organization for cause, to support a safe, compliant, and drug-free workplace.
Ongoing Compliance Requirements: Maintain up-to-date compliance with all required annual renewals, including professional licenses, certifications, physical examinations, TB testing, and mandatory regulatory trainings as assigned by the San Diego American Indian Health Center (SDAIHC
Excellent verbal and written communication skills.
Excellent interpersonal, negotiation, and conflict resolution skills.
Excellent organizational skills, record-keeping skills and attention to detail.
Excellent time management skills with a proven ability to meet deadlines.
Strong analytical and problem-solving skills.
Ability to prioritize tasks and to delegate them when appropriate.
Ability to act with integrity, professionalism, and confidentiality.
Proficient with Microsoft Office Suite or related software.
Proficiency with or the ability to quickly learn the organizations EMR and other billing software systems.
Able to lift/move up to 20 pounds, move from place to place.
Able to stand, bend and reach for prolonged periods.
Ability to do math, organize and prioritize workload, work effectively and efficiently under stress.
Ability to supervise, multitask, understand, and follow instructions.
Ability to proficiently read, write, speak, and understand English.

Nice To Haves

FQHC background.
Familiarity with community health clinics and/or Indian Health Clinics.
ECW EHR.
Prefer a master’s degree from an accredited university or professional school for a Nursing, and at least 2 years of experience; or a BA and 4 years’ experience

Responsibilities

Coordinate with clinical staff to conduct comprehensive health assessments, including medical, behavioral, functional, and social determinants of health (SDOH), for each assigned ECM member.
Coordinate with clinical staff to Develop, implement, and update individualized care plans that reflect member goals, needs, and measurable outcomes, ensuring alignment with HRSA core clinical performance measures (e.g., diabetes, hypertension, depression screening).
Coordinate care across primary care, behavioral health, dental, substance use, housing, and specialty systems to address whole-person health needs in accordance with HRSA’s integrated services modelTrack and follow up on referrals to specialty care, housing services, substance use treatment, behavioral health, and other wraparound supports.
Coordinate multidisciplinary team meetings and case conferences with providers, behavioral health clinicians, community health workers, and social services
Document all case management interactions and interventions in the EHR and ECM tracking system within required timeframes.
Collaborate with the Managed Care Plan’s ECM team and CalAIM stakeholders as needed to ensure program compliance and alignment.
Identify and resolve barriers to care, including access to transportation, medication adherence, or cultural/language needs.
Participate in population health initiatives, quality improvement activities, and care team huddles to enhance patient outcomes and operational effectiveness
Monitor high-risk member panels using risk stratification tools and provide appropriate intensity of services based on member acuity.
Provide patient navigation support, health system education, and linkage to resources.
Maintain current knowledge of ECM program requirements, Medi-Cal managed care benefits, and community resources.
Collaborate with CHW’s and Navigators as part of the care team.
Maintain complete, timely, and compliant documentation for all services provided, supporting HRSA grant deliverables, compliance monitoring, and managed care ECM reporting
Respond to crises and escalating needs with urgency, de-escalation skills, and coordination with emergency or behavioral health resources.
Participate in the annual Uniform Data System (UDS) data collection process, contributing relevant case management and clinical coordination data.
Maintain confidentiality and comply with all HIPAA regulations and ECM program data-sharing requirements.
Active involvement in the community to educate about risk factors for chronic disease, increase community-based screening methodologies, and recruit newly diagnosed individuals to SDAIHC for treatment and management.
Assist with program evaluation, including performance measurement, member satisfaction surveys, and continuous quality improvement related to HRSA funding expectations and ECM contractual obligations
Adhere to organizational and departmental policies and procedures.
Perform the clinical and administrative duties necessary to meet the goals and objectives of the grant.
Maintain 50 patient case load after 6 months
Other duties as assigned.