ECM/CS Care Manager

Job Title: ECM/CS Care Team Manager

Reports to: Lead Care Manager

Works in collaboration with: Organizational leadership & staff, medical/health care providers (primary care

physicians, nursing staff, mental health works), Community Supports organizations.

The Care Team Manager is responsible for delivering Enhanced Care Management (ECM) and Community Support (CS)

services through our program, with a focus on housing support. This role includes guiding clients and their families

through the healthcare system, community resources, and social services. The Care Team Manager utilizes an integrated

approach to care management and community outreach, prioritizing efforts that promote, maintain, and improve the health

of clients and their families.

Key responsibilities include providing social support and informal counseling, advocating for client health and community

service needs, conducting intakes and needs assessments, connecting clients with clinical and non-clinical services,

educating clients on available resources, assisting with housing and service applications, offering landlord/tenant

education, coordinating with community resources and facilities, identifying funding opportunities for clients, and

maintaining accurate documentation of services and care plans for those enrolled in ECM.

Essential Job Duties and Responsibilities:

Intake and Assessments: Conduct intakes and assessments to identify clients' needs for Enhanced Care

Management (ECM) and Community Support (CS), including health requirements and barriers to accessing

services.

• Client Education and Enrollment: Educate clients about ECM and CS services, assist with enrollment, and

serve as the primary liaison between clients and the services they require.

• Support and Navigation: Guide individuals and families through the healthcare system, supporting them as they

transition towards improved self-care and healthcare management.

• Relationship Building: Establish trusting relationships with clients and their families, providing general support

and encouragement.

• Ongoing Support: Provide continuous follow-up, basic motivational interviewing, and goal setting with clients,

families, and caregivers.

• Barrier Removal: Facilitate conversations with clients to remove barriers preventing access to health and social

services; conduct face-to-face outreach for appointment scheduling, needs assessment, and care gap closure.

• Social Determinants of Health: Meet clients in various settings (clinic, facility, or home) to identify social

determinants of health impacting their well-being.

• Care Planning: Collaborate with the care team to develop individualized, linguistically, and culturally

appropriate care plans for each ECM-enrolled client.

• Resource Access: Assist clients in accessing health-related services and community resources, such as

accompanying them to specialist appointments and assisting with enrollment forms.

• Communication Facilitation: Act as a communication bridge between clients, families, healthcare providers, and

community-based organizations.

Documentation: Record interactions with clients in the organization and managed care platforms within 24 hours

of contact.

• Follow-Up: Maintain contact with clients through phone calls, home visits, and other settings to monitor their

progress.

• Goal Setting and Referrals: Help clients set personal health-related goals, attend appointments, and provide

referrals to community agencies as needed.

• Transportation Assistance: Connect clients with transportation resources and provide appointment reminders in

special circumstances.

• Housing Support: Assist with housing applications, gather and compile supporting documents, engage potential

landlords, and conduct pre-inspections to ensure housing units meet Housing Quality Standards.

• Landlord/Tenant Mediation: Provide mediation services to address issues and help clients maintain permanent housing.

Funding Research: Research and secure funding for security deposits, moving expenses, furniture, and

household items for clients transitioning to the community.

• Collaboration: Work closely with medical providers and other clinical personnel to ensure clients receive

comprehensive and coordinated care.

• Community Resource Knowledge: Stay updated on community resources relevant to client needs.

• Care Team Communication: Provide consistent communication to the care team to evaluate client progress,

ensuring reports accurately reflect their status.

• Advocacy: Act as a client advocate and liaison between clients, their families, and community service agencies.

• HIPAA Compliance: Maintain HIPAA compliance at all times while managing a caseload of clients.

Competencies:

• Organizational Skills: Effectively manage multiple priorities while remaining professional and calm.

• Diversity Engagement: Ability to work with diverse populations, including children and teenagers.

• Telephone Skills: Possess effective telephone communication skills.

• Confidentiality: Maintain a high level of confidentiality due to the sensitivity of materials and information

handled.

• Process Improvement: Ability to suggest improvements for workflow or system efficiency.

• Independence: Work independently, being self-directed and flexible, with minimal supervision.

• Accuracy: Perform tasks with a high level of accuracy, even in high-volume situations.

General Expectations:

Commitment to Mission: Demonstrate commitment to the program's mission.

• Professional Behavior: Exhibit professionalism and consistently promote respect, honesty, and dignity for

clients, families, and healthcare team members.

• Pursuit of Excellence: Engage in the continuous pursuit of excellence and teamwork to improve client care.

• Meeting Participation: Attend all scheduled staff meetings and actively participate in team huddles.

• Punctuality: Be punctual for work and manage time effectively.

• Work Completion: Complete the required amount of work within the allotted time.

• Professional Appearance: Maintain a neat and professional appearance.

• Confidentiality: Adhere to confidentiality laws and principles, keeping information about program operations,

clients, and employees confidential.

• Other Duties: Perform other duties as assigned.

Qualifications:

High School Diploma or Equivalent: Required; Associate’s degree preferred.

• Valid California Driver’s License: Required.

• Professional Experience: Minimum of 2 years working in a similar setting or social service program.

• Diverse Population Engagement: At least 1 year of experience working with diverse and marginalized

populations.

• Community-Based Setting: 1 to 2 years of experience in a community-based environment preferred.

• English Proficiency: Strong written and oral communication skills required.

• Bilingual Ability: Fluency in both English and Spanish is preferred.

• Computer Proficiency: Basic computer skills required; experience with Electronic Medical Records (EMR)

systems preferred.

• Multicultural Competence: Experience working in multicultural settings and a willingness to learn and

understand various cultures, perspectives, and norms.

• Communication Skills: Excellent listening abilities and appropriate use of language to effectively interact with

clients and team members.

• Supportive Presence: Ability and willingness to provide emotional support, encouragement, and motivation to

clients.

• Community Representation: Understanding of and ability to represent the community served.

Job Type: Full-time

Pay: $45,000.00 - $52,000.00 per year

Benefits:

• Paid sick time
• Paid time off
• Retirement plan

Schedule:

• 8 hour shift
• Monday to Friday

Experience:

• Medical coding: 1 year (Preferred)
• Case management: 2 years (Preferred)

Ability to Commute:

• Merced, CA 95340 (Required)

Willingness to travel:

• 50% (Preferred)

Work Location: In person

Salary : $45,000 - $52,000