Lead Care Coordinator

CENTER FOR HUMAN SERVICES•Modesto, CA

7d•Onsite

About The Position

The Lead Care Coordinator serves as the primary care manager for Medi-Cal Members enrolled in the Enhanced Care Management (ECM) program. This role functions as the central point of contact for the Member, their family, Authorized Representative (AR), caregiver(s), and multidisciplinary care team. The Lead Care Coordinator delivers whole-person, culturally responsive care by addressing medical, behavioral, developmental, oral health, and social needs through collaboration with internal staff and external partners. This position plays a key role in expanding access to services and ensuring compliance with Department of Health Care Services (DHCS) and Managed Care Plan (MCP) ECM requirements.

Requirements

High school diploma or GED required.
Minimum of two (2) years of experience in case management, system navigation, social services, or closely related work.
Proficiency with computer-based technology including Electronic Health Records.
Ability to engage and build trust with diverse and underserved populations.
Pass agency paid criminal justice screening including fingerprints.
Pass agency paid TB (Tuberculosis) screening.
Pass agency paid health screening and/or drug testing, if required.
Valid California driver’s license and proof of auto insurance coverage required.
Pass agency paid MVR clearance with no more than 2 points - if you are under the age of 25 our insurance company will not allow any points.

Nice To Haves

Bachelor’s degree in social work, psychology, nursing or related field, preferred.
Prior experience as a Community Health Care Worker, Navigator or similar role, preferred.
Knowledge of CalAIM or Medi-Cal ECM/CS, preferred.
Proficiency in Motivational Interviewing, Harm Reduction, and Trauma-Informed Care, preferred.

Responsibilities

Use comprehensive assessments to develop individualized care plans addressing physical health, behavioral health, substance use, oral health, trauma, housing, employment, and social support needs.
Collaborate with the Member, family, caregivers, and care team to maintain a whole-person care plan.
Reassess and update care plans at least every six (6) months or as the Member’s needs change.
Serve as the primary point of contact for the Member, family, authorized representative, caregiver(s), and multidisciplinary care team.
Coordinate communication and services among providers, community partners, and MCP representatives to ensure seamless and non-duplicative care.
Facilitate warm handoffs between care settings, including hospital discharges and other transitions.
Work with the ECM Clinical Consultant (licensed clinician) for oversight, guidance, and clinical support.
Provide all ECM Core services as defined by DHCS, including outreach and engagement, comprehensive assessment and care planning, enhanced care coordination, health promotion, transitional care services, member and family support, referral and linkage to community/social support services.
Provide education to Members and families about care plans, treatment options, and self-management strategies.
Deliver services in the Member’s preferred setting (field, home, community, office, or telehealth).
Requires field-based work, home visits, or travel within the service area.
Maintain accurate, timely, and complete documentation in accordance with agency, MCP, and DHCS requirements.
Ensure all reports, assessments, and care plans meet ECM quality and data submission standards.
Provide services consistent with DHCS Culturally and Linguistically Appropriate Services (CLAS) standards.
Demonstrate respect for diverse cultural values, beliefs, and linguistic needs.
Participate in regular supervision, case reviews, and multidisciplinary team meetings.
Support and guide care team members to ensure coordinated delivery of ECM services.
Attend required trainings and maintain up-to-date knowledge of CalAIM, ECM, and care coordination best practices.
Represent the agency in a professional and competent manner.
Advocate for the best interests of the agency and clients we serve.
Establish and maintain effective working relationships with the general public, co-workers, clients, supervisors and members of diverse cultural and linguistic backgrounds regardless of race, color, creed, religion, gender, sexual orientation, gender identity or expression, national origin, age, ancestry, political affiliation, citizenship, disability, medical conditions, marital status, amnesty and military or veteran status.
Will promote and support a culturally and linguistically diverse workforce and be responsive to the population within our service area.
Maintain confidentiality and confidential information in accordance with legal standards and/or agency regulations.
Participate in assigned scheduled agency meetings, in-service trainings, conferences and other trainings as determined by the supervisor. This includes serving as an agency representative at assigned community meetings.
Observance of assigned working hours and program appointments by demonstrating promptness and thorough preparation.
Performance of assigned duties with a positive attitude and in the spirit of teamwork, collaboration and cooperation.
Communicate effectively both orally and in writing.
Perform job duties in a safe manner to ensure a safe working environment for oneself and others.
Participates in and/or supports agency fund development activities and events.
Preparation of assigned reports, work records, statistical data, job performance evaluations, work plans, etc. in a timely manner.