Bilingual ECM Care Navigator (In-Home & Community)

Gracelight Community Health; Los Angeles (CA); Hybrid; USD 60,000 - 80,000; Full time

Job summary

Gracelight Community Health seeks an ECM Care Coordinator to deliver integrated care to Medi-Cal members with complex needs, including housing, food insecurity, and transportation barriers. You will conduct home and clinic visits, assess medical and social needs, and develop personalized care plans with the care team.

Bilingual English/Spanish required to serve diverse patients. You will manage referrals, coordinate services across settings, document encounters in the EHR, and support patient

Qualifications

• High School Diploma or GED required.
• Completion of an accredited MA or LVN program required.
• Minimum of 2–3 years of clinical or case management experience in community settings.
• Familiarity with Medi-Cal ECM model and CalAIM desirable.
• Experience with Electronic Health Record (EHR) systems.
• Ability to travel locally within Los Angeles County.

Responsibilities

• Conduct outreach and engage potential ECM-eligible patients, explaining benefits and enrollment.
• Perform comprehensive assessments to identify medical, behavioral health, dental, developmental, and social needs.
• Develop and monitor personalized care plans addressing social determinants of health.
• Coordinate care across primary, specialty, hospital, and community services.
• Facilitate referrals to medical, behavioral health, social, housing, food, and transportation resources.
• Coordinate discharge planning and transitions of care with hospital staff.
• Provide health promotion and self-management education to empower patients.
• Document all encounters and plans in the EHR accurately and timely.
• Ensure compliance with DHS requirements, plan guidelines, and Gracelight policies.
• Participate in audits, trainings, and interdisciplinary team meetings.
• Build relationships with community agencies and housing providers.

Skills

Bilingual English/Spanish

EHR documentation

Education

High School Diploma or GED

MA or LVN program completion

Tools

EHR systems

Job description

Gracelight Community Health seeks an ECM Care Coordinator to deliver integrated care to Medi-Cal members with complex needs, including housing, food insecurity, and transportation barriers. You will conduct home and clinic visits, assess medical and social needs, and develop personalized care plans with the care team.

Bilingual English/Spanish required to serve diverse patients. You will manage referrals, coordinate services across settings, document encounters in the EHR, and support patient