Outreach for ECM services

TrueCare•Vista, CA

1d•$23 - $32

About The Position

TrueCare is a trusted healthcare provider serving San Diego and Riverside Counties, offering compassionate and comprehensive care to underserved communities. We are committed to making healthcare accessible to everyone, regardless of income or insurance status. With a focus on culturally sensitive, affordable services, TrueCare aims to improve the health of diverse communities. Our vision is to be the premier healthcare provider in the region, delivering exceptional patient experiences through innovative, integrated care. The Enhanced Care Management (ECM) Enrollment Specialist provides comprehensive care management to patients with serious, complex, or chronic health problems or psychosocial issues; screens patients for eligibility and provides referrals to various healthcare programs; and assists with enrollment, explains program benefits, and ensures patients receive needed coverage for continued care. The Specialist works directly with patients, families, community partners, and healthcare providers to develop and implement individualized care plans that address the physical, behavioral, and social drivers of health by providing care coordination, comprehensive transitional care, individual and family support services, crisis intervention, and referrals to TrueCare and external community and social support services. Grant funded through Dec 31, 2026

Requirements

High school diploma or equivalent.
At least one (1) year of care coordination experience, or one (1) year of referrals experience.
Bilingual in English and Spanish.
Knowledge of medical terminology and care coordination.
Computer proficiency, particularly with electronic health/medical record systems and the Microsoft Office suite, including Outlook and Word.

Nice To Haves

Associate’s degree in social work, human services, counseling, human relations, or a related field.

Responsibilities

Provide Enhanced Care Management (ECM) services and implement Individualized Care Plans (ICPs) to patients with serious, complex, or chronic health problems or psychosocial issues.
Conduct outreach to potential patients, including mobile outreach to community and field-based locations where individuals live, seek shelter, seek care, or find the most easily accessible within Managed Care Program (MCP) guidelines, to determine eligibility for services; document outreach attempts on a daily basis.
Perform enrollment screening with eligible individuals and assist patients with enrollment in TrueCare programs.
Collect and enter patient personal, medical, and statistical information into electronic health records (EHR) system to ensure effective coordination of care.
Maintain a caseload of patients; perform frequent outreach through field visits, home visits, phone calls, and/or other electronic methods as appropriate to attain updates on patients’ health status and provide effective coordination of care.
Identifies goals for care management with patients; monitors patients’ progress and modifies goals as appropriate.
Facilitate patient access to appropriate medical and specialty providers.
Connect patients to relevant community resources with the goal of enhancing patient health, well-being and increasing patient satisfaction.
Schedule appointments according to clinical and scheduling guidelines.
Document pertinent care management information (e.g., plans, interventions, goals).
Participate in case conferences and periodic meetings as required.
Engage with potential and eligible patients using principles of trauma-informed care and harm-reduction practices.