Care Manager - ECM

Vista Community Clinic; Vista (CA); On-site; USD 34,000 - 36,000; Full time

Benefits offered by this job

Competitive compensation & benefits

Medical, dental, vision

Company-paid life insurance

Flexible spending accounts

403(b) retirement plan

Job summary

Vista Community Clinic (VCC) in Vista, CA is seeking an ECM Care Coordinator to join our multi‑disciplinary team. You will coordinate care for assigned health plan members and families, arranging ECM and Community Supports to improve health outcomes and address social determinants of health.

You will develop individualized care plans, coach patients using motivational interviewing, and serve as the main contact for patients and families throughout care transitions.

Qualifications

• Bachelor’s degree in social work, psychology, counseling, or behavioral science.
• Two years’ experience in a healthcare setting or with patient education and advocacy.
• Resourceful community liaison navigating through complex health systems and community services.
• Bilingual English/Spanish.

Responsibilities

• Coordinate ECM and Community Supports with the care team and ECM Members and/or family.
• Develop individualized care plans integrating clinical and non‑clinical needs to achieve health goals.
• Coach patients and caregivers using motivational interviewing and trauma‑informed language.
• Act as point of contact for patients and families throughout the care team.
• Identify referrals for social services addressing housing instability and SDOH.
• Visit patients at home or in their community settings for assessments and support.
• Monitor medication adherence with ECM RN Clinical Consultant.
• Perform population management tasks: scheduling, recalls, referrals, and portal callbacks.

Skills

Bilingual English/Spanish

Community liaison

Education

Bachelor’s degree in social work, psychology, counseling, behavioral science

Job description

Overview

At Vista Community Clinic (VCC), we believe healthcare is more than medicine, it’s about hope, community, and impact. For over 50 years, we’ve been a leader in the community clinic movement, growing from a small volunteer-driven effort in Vista to a nationally recognized network of state-of-the-art clinics across San Diego, Orange, Los Angeles, and Riverside counties. Today VCC has 14 clinics serving over 70,000 patients annually, we continue our mission of delivering exceptional, patient-centered care where it’s needed most.

As a private, non-profit, multi-specialty outpatient clinic, VCC provides more than healthcare, we provide opportunity. Here your skills are celebrated, your growth is supported and your work makes a difference. We know that our success is a direct result of the exceptional talents and dedication of our employees.

For eligible employees, benefits include:

• Competitive compensation & benefits
• Medical, dental, vision
• Company-paid life insurance
• Flexible spending accounts
• 403(b) retirement plan

Why VCC?

• Winner of the 2025 HRSA Gold Medal for Outstanding Care, placing VCC among the top 10% of Federally Qualified Health Centers in the U.S.
• Recognized by HRSA as a National Quality Leader in Behavioral Health and Diabetes and for excellence in Preventive Health and Health IT.
• A robust training & development culture to help you grow and advance your career.
• A workplace built on respect, collaboration and passion for care.

Responsibilities

Operate as part of the patients’ multi‑disciplinary care team and responsible for interacting directly with the assigned health plan’s ECM Members and/or family, Authorized Representatives, caretakers and/or other authorized support person(s) as appropriate to coordinate all aspects of ECM and any Community Supports. Work with the ECM Clinical Nurse Specialist and other program staff to care coordinate designated populations of focus panel to ensure appropriate input is obtained to effectively coordinate all primary, behavioral, developmental, oral health, LTSS, ILOS and other services that address social determinants of health (SDOH).

• Conduct outreach, enrollment and care management to selected population of focus determined by assigned health plan(s)
• Develop an individualized comprehensive management care plan integrating clinical and non‑clinical needs to achieve health goals designed to improve functional status, health status, or prevent decline
• Coach patients and caregivers using evidence‑based motivational interviewing techniques and trauma‑informed care language to address critical issues to help patients develop achievable self‑management care plan goals, presenting new skills using a step‑by‑step process
• Act as point of contact for patients and families involved in patients’ care team through any form of agreed‑upon communication
• Support patients in the development of health care goals by conducting appropriate assessments that uncover comprehensive physical, mental, social and Community Supports’ needs
• Visit patients in their homes or where they seek care, or prefer to access services in their community using and completing patient interviews on health condition knowledge and motivation to engage in self‑management
• Identify and initiate referrals for social service programs, such as financial, community and state supportive services alleviating housing instability and other social determinants of health
• Work with ECM RN Clinical Consultant to monitor medication adherence to include medication management and reconciliation periodically for changes, especially at time of care transitions
• Perform population management tasks such as appointment scheduling, prevention and screening recalls, monitoring referrals, patient portal callbacks and responding to telephone messages

Qualifications

Minimum

• Bachelor’s degree in social work, psychology, counseling, behavioral science
• Two years’ experience in a healthcare setting, preferably providing direct patient care, or with duties involving patient education and advocacy.
• Resourceful community liaison experience navigating through complex health systems and community services
• Bilingual English/Spanish
• Valid CA driver’s license and vehicle insurance, reliable transportation; minimum two years’ driving experience; no more than two violations or a single ticket/accident valued at more than one point on driving record

Preferred Qualifications

• Experience working with patients with a serious mental illness and/or substance use disorder

Pay Range

• $25.00 - $26.00 Depending On Experience