Lead Care Manager (ECM Program)

Therapeutic Play Foundation • Los Angeles, CA

22h • Hybrid

About The Position

The Lead Care Manager (LCM) serves as the primary lead and central coordinator of client services within the Therapeutic Play Foundation’s interdisciplinary Support Squad model, under the guidance of the Clinical Operations Manager and in collaboration with the Programs Administrative Manager. The role coordinates whole-person care for clients with medical, behavioral health, and social support needs through trauma-informed, culturally responsive engagement and interdisciplinary collaboration.

The LCM maintains oversight of care coordination, engagement workflows, transitions of care, assessment timelines, and interdisciplinary communication. The position works closely with Community Health Workers, Medical Virtual Assistants, Clinical Consultants, Supervising Practitioners, STRTP staff, and administrative teams to support timely services and access to healthcare and community-based resources. The LCM also coordinates transitions for clients entering or leaving healthcare systems and higher levels of care, consistent with ECM care coordination and DHCS transition-of-care expectations.

This is a full-time hybrid role serving Los Angeles County through office, community, and telehealth work. In-person attendance may be required according to operational and client-care needs. Some evening or weekend availability may occasionally be required. The role includes community outreach and may require lifting and carrying approximately 15–25 pounds, with or without reasonable accommodation.

Requirements

• Experience in case management, care coordination, social services, health navigation, behavioral health, or a related field; one year is preferred.
• Strong communication, organization, relationship-building, and documentation skills.
• Ability to complete documentation and required paperwork in collaboration with and on behalf of clients in a timely manner.
• Comfort navigating electronic health record systems, data platforms, and healthcare technology systems.
• Ability to work independently and thrive in a collaborative interdisciplinary care model.
• A trauma-informed, culturally responsive, and community-centered approach.
• Technology proficiency with EHR systems, Google Workspace, Slack, and related platforms.
• Comfort working in a fast-paced, evolving CalAIM and community healthcare environment.
• Flexibility, communication, professionalism, and responsiveness to interdisciplinary coordination and evolving client-care and program needs.
• Ability to lift and carry approximately 15–25 pounds, with or without reasonable accommodation, for community outreach activities.
• Availability during scheduled working hours; occasional evening or weekend availability may be required.

Nice To Haves

• Familiarity with Medi-Cal populations, CalAIM, Enhanced Care Management (ECM), transitions of care, or community-based healthcare systems.
• Bilingual Spanish/English skills.
• Valid driver’s license for field engagement and community-based services.

Responsibilities

• Lead and coordinate services for an assigned caseload of clients enrolled in ECM and/or Healthcare Access programs.
• Build trusting relationships with clients and support them in navigating medical, behavioral health, and social service systems.
• Conduct regular relationship-building and client follow-up activities each month.
• Oversee client engagement, service coordination, referrals, interdisciplinary communication, and continuity-of-care activities.
• Coordinate care across providers, community agencies, healthcare systems, and support programs to reduce barriers and improve health outcomes.
• Provide warm handoffs and help clients connect with medical care, behavioral health services, social services, housing resources, and community supports.
• Coordinate and monitor transitions of care involving hospitals, emergency departments, psychiatric facilities, incarceration settings, residential programs, shelters, skilled nursing facilities, detox programs, and other care settings.
• As needed, participate in supportive engagement, interdisciplinary coordination, and wellness-centered programming connected to the Short-Term Residential Therapeutic Program (STRTP).
• Ensure the Wellness Pathway Form is completed and reviewed before onboarding clients into the EHR, including EXYM.
• Complete, finalize, and maintain ECM enrollment documentation, comprehensive assessments, and individualized care plans in collaboration with clients and interdisciplinary team members.
• Ensure comprehensive assessments are completed within 45 days of ECM enrollment and care plans and/or treatment plans within 60 days of enrollment for ECM and Healthcare Access/Behavioral Health clients.
• Ensure care plans reflect client strengths, goals, barriers, wellness priorities, and interdisciplinary recommendations; monitor and update assessments and plans as indicated.
• Coordinate with Community Health Workers and Medical Virtual Assistants who assist with outreach, scheduling, data gathering, LANES/PointClickCare review, and EHR support.
• Review measurement-based care outcomes in Blueprint Health and communicate concerns, symptom changes, or elevated clinical needs to Clinical Consultants as appropriate.
• Oversee Blueprint Health screening tools and client-reported outcomes to identify when additional clinical support or behavioral health intervention may be needed.
• Ensure Clinical Consultants and/or behavioral health providers are informed when clients may need appointments, reassessments, crisis support, or other interventions.
• Schedule and coordinate multidisciplinary team meetings, clinical consultations, and interdisciplinary case discussions as needed.
• Communicate regularly with the Clinical Operations Manager and Clinical Consultants about client needs, safety concerns, barriers to care, or changes in functioning.
• Facilitate or co-facilitate monthly Wellness Labs grounded in the Brain Well-Being Model® and Collective Care framework.
• Support culturally inclusive, trauma-informed engagement across client interactions and community programming.
• Send monthly e-newsletters and wellness-related updates to assigned clients about TPF programs, community events, and available resources.
• Maintain timely, accurate, audit-ready documentation in organizational systems and electronic health records.
• Complete outreach notes, case management documentation, care coordination activities, assessments, and care plans in accordance with organizational policies, HIPAA standards, and ECM/behavioral health program requirements.
• Track referrals, authorizations, outreach efforts, and client engagement activities to support compliance and continuity of care.

Benefits

• Opportunities for growth in CalAIM, behavioral health, and integrated care coordination.
• Supportive interdisciplinary team with weekly case huddles and clinical collaboration.
• Hybrid schedule with field-based work and community engagement.
• Wellness culture that values staff whole-person well-being.
• Mission-driven team committed to community healing and collective care.
• Creative, wellness-centered programming grounded in art, gardening, movement, and play.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed