Care Coordinator - ECM

Mercy House; Santa Ana (CA); On-site; USD 32,000 - 34,000; Full time

Benefits offered by this job

Medical coverage options

Dental coverage

Vision coverage

Paid Time Off

Flexible Spending Account

Employee Assistance Program

403(b) retirement plan with employer-m

On-the-job training and orientation

Mileage reimbursement

Employee referral program

Professional growth opportunities

Job summary

Mercy House seeks an Enhanced Care Management (ECM) Lead Care Manager in Santa Ana to coordinate medical and non-medical services for individuals experiencing homelessness. This role emphasizes patient-centered, team-based care with CalOptima Health guidelines and comprehensive care planning.

The position requires a bachelor's degree or equivalent experience in social services, with strong engagement, documentation, and collaboration skills.

Qualifications

• Bachelor’s degree preferred; candidates with 2+ years of direct experience serving homeless, low-income populations may qualify.
• Experience in care coordination or case management for homelessness, high utilizers, mental illness/SUD, or transitions between facilities.
• Knowledge of HMIS/CalOptima Health, Housing First, Harm Reduction, Motivational Interviewing, trauma-informed care, and crisis intervention is preferred.

Responsibilities

• Maintain a caseload of 17–25 individuals and develop health needs assessments and care plans with measurable goals.
• Engage, enroll, and assist ECM members in services and address barriers to care.
• Coordinate services at member homes or community locations in line with CalOptima Health guidelines.
• Coordinate transportation, appointments, and accompany members to critical visits as needed.
• Advocate with healthcare professionals and collaborate with hospitals and providers to coordinate care.

Skills

Care coordination

Engagement

Communication

Spanish language

Education

Bachelor’s degree in Social Work or related field

2+ years direct homeless service experience

Tools

Microsoft Office

Job description

Job Details

Job Location: Santa Ana, CA 92705 Position Type: Full Time Education Level: 4 Year Degree Salary Range: $23.00 - $25.00 Hourly Travel Percentage: Up to 50% Job Shift: Day Job Category: Case Management Status: Full-Time, Non-Exempt

Pay: $23.00-$25.00/hour

Schedule: Monday - Friday 8:30 a.m. - 5:00 p.m.

Mission Statement:

"To be a leader in ending homelessness by providing a unique system of dignified housing opportunities, programs, and supportive services."

Benefits Offered:

• Flexible medical coverage options
• Voluntary dental, vision, life, accident, critical illness, and hospital insurance
• Paid Time Off (PTO)
• Flexible Spending Account (FSA)
• Employee Assistance Program (EAP)
• 403(b) retirement plan with up to 3% employer matching
• Paid on-the-job training and orientation
• Mileage reimbursement
• Employee referral program
• Opportunities for professional growth and advancement

Job Summary:

The Enhanced Care Management (ECM) Lead Care Manager is responsible for coordinating all covered medical and non-medical supportive services the member needs, including physical, behavioral, dental, developmental, oral health, long-term services and supports (LTSS), Specialty Mental Health Services, Drug Medi-Cal/Drug Medi-Cal Organized Delivery System services, Community Supports, and other services that address social determinants of health (SDOH) needs, regardless of setting. The ECM Lead Care Manager will work closely with the CalAIM Community Supports Program staff to provide team-based, patient-centered care for clients experiencing homelessness and at risk of homelessness.

Essential Duties and Responsibilities:

Client/Service Delivery

• Maintain a minimum caseload of 17-25 individuals and meet with members as needed to complete Health Needs Assessments, Care Plans, which include short- and long-term measurable goals
• Engage, outreach, and enroll eligible ECM members in services and help address barriers
• Offer services where the member lives, seeks care, or finds most easily accessible, within CalOptima Health guidelines
• Support and engage members in their treatment, including coordination for medication review and/or reconciliation, scheduling appointments, providing appointment reminders, coordinating transportation when needed for medical appointments, accompanying members to critical appointments, and identifying and helping to address other barriers to member engagement in treatment
• Accompany members on office visits as needed and according to CalOptima Health guidelines
• Advocate on behalf of the member with healthcare professionals and work with hospital staff on discharge plans
• Collaborate with area hospitals, behavioral health providers, specialists, dental providers, providers of services for Long-Term Services of Support (LTSS), and other associated entities such as Community Supports, as appropriate, to coordinate member care
• Use motivational interviewing and trauma-informed care practices
• Monitor treatment adherence (including medication)
• Provide health promotion and self-management training to enrolled ECM members
• Report ECM patient progress, concerns, and needs to the multidisciplinary team to improve patient care
• Other duties may be assigned or modified

Team/Staff Relations

• Work as a Mercy House team member with all staff and volunteers to implement the mission and core values of the agency
• Attend regular internal and external agency meetings
• Work as part of a team to plan and develop resident programs
• Work in a team environment, fast-paced environment, be flexible, adaptable to sudden changes, trustworthy, reliable, and empathetic
• Communicate effectively with diverse populations

Administration

• Keep accurate, up-to-date documentation on all clients, including but not limited to Health Needs Assessments and Care Plans
• Assist with all data collection systems
• Assure deadlines are met
• Utilize computers and appropriate software (e.g., Microsoft Word, Outlook, Excel, PowerPoint) and/or specific systems applicable to the position
• Respond to calls and emails in a timely mannerPerform tasks independently and prioritize workload

Knowledge of:

• Confidentiality and the legal and ethical issues pertaining to case management
• Effective documentation and guidelines

QualificationsRequirements:

Education and Experience

• Bachelor’s degree in Social Work or related field preferred; candidates without a degree may qualify with 2+ years of direct experience serving homeless, low-income, and diverse populations
• Preferred minimum of1year in care coordination/case management, especially with homelessness, high utilizers, serious mental illness/SUD, nursing-facility transitions, or intellectual/developmental disabilities
• Preferred skills related to outreach, engagement, care planning/coordination, health promotion, transitional care, education, and social-service coordination
• Preferred knowledge of HMIS/CalOptima Health, Housing First, Harm Reduction, Motivational Interviewing, Patient-Centered/Trauma-Informed Care, and crisis intervention
• Experience supporting individuals/families with mental illness and substance use in accessing healthcare and community resources
• Computer literacy and proficiency with Microsoft programs are required

General

• A valid CA driver’s license, proof of insurance and a reliable vehicle is required. Comfortable with utilizing your own vehicle to conduct home visits, visiting clients at shelters, meeting clients out in the community etc.
• Ability to work effectively with a diverse population; plan, organize and prioritize duties; crisis intervention as needed; clearly communicate information and instructions verbally and in written form; maintain a positive, professional, and safe environment while on duty; and establish and maintain effective working relationships with others
• Dependability, responsibility, and the ability to communicate effectively and respectfully are mandatory skills
• Fluency in Spanish is of significant value

Physical Requirements

• Ability to lift items weighing up to 50 pounds
• Prolonged periods of sitting at a desk and working on a computer