ECM Care Coordinator

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

Summary

The ECM (Enhanced Care Management) Care Coordinator plays a crucial role in Gracelight Community Health's commitment to delivering integrated, patient-centered care. This position is responsible for providing comprehensive care management services to eligible Medi-Cal members with complex medical, behavioral, and social needs. The ECM Care Coordinator will work directly with patients in their homes, communities, and Gracelight clinic settings to navigate healthcare systems, connect with vital resources, and develop personalized care plans that address their unique circumstances and social determinants of health. Fluency in both English and Spanish is required for this role to effectively serve our diverse patient population.

Responsibilities

• Conduct outreach and engage with potential ECM-eligible patients, explaining the program benefits and facilitating enrollment.
• Perform comprehensive, patient-centered assessments to identify medical, behavioral health, dental, developmental, and social needs, including barriers to care such as housing instability, food insecurity, and transportation.
• Ensure care plans address identified social support and health-related social needs such as housing transition/navigation, medically tailored meals, and asthma remediation.
• Oversee the effective implementation of care plans, monitoring progress, and making necessary adjustments in collaboration with the patient and care team.
• Act as the primary point of contact and central hub for coordinating all aspects of the patient's care across various settings, including primary care, specialty care, hospitals, and community-based organizations.
• Facilitate referrals and linkages to appropriate medical, behavioral health, social, educational, housing, food, transportation, and other necessary services.
• Coordinate with hospital staff on discharge planning and ensure seamless transitions of care.
• Provide health promotion, self-management education, and support to empower patients in managing their own health.
• Maintain accurate, timely, and comprehensive documentation of all patient encounters, assessments, care plans, and interventions in the Electronic Health Record (EHR) and other designated tracking systems.
• Ensure all documentation and program activities comply with Department of Health Services (DHS) requirements, health plan guidelines, and Gracelight's policies and procedures.
• Participate in all health plan audits and seminars as applicable.
• Regularly participate in interdisciplinary team meetings and case conferences to discuss patient progress and strategize care interventions.
• Form and foster relationships with community agencies, housing providers, and other relevant organizations to expand resource networks for patients.
• Advocate for patient rights, preferences, and access to necessary services.
• Maintain current knowledge of ECM requirements, updates, and best practices.

Qualifications

Education and Experience

• High School Diploma or GED required.
• Completion of an accredited Medical Assistant (MA) or Licensed Vocational Nurse (LVN) program required.
• Minimum of 2–3 years of experience in a clinical setting or in case management/care coordination roles, preferably within a community-based healthcare setting or with vulnerable populations such as individuals experiencing homelessness or chronic conditions.
• Familiarity with Medi‑Cal, Enhanced Care Management (ECM) model, and CalAIM initiatives is highly desirable.
• Experience with Electronic Health Record (EHR) systems.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Language Skills

• Fluent in both English and Spanish (speaking, reading, writing) to effectively communicate with patients and families.
• Ability to travel locally within Los Angeles County to conduct in‑person patient visits.

Knowledge, Skills, and Abilities

• Ability to read, analyze, and interpret complex documents such as policies, procedures, guidelines, contracts, and architectural drawings.
• Ability to compose professional reports, correspondence, and presentations.
• Ability to communicate effectively and persuasively, both verbally and in writing, with employees, vendors, regulatory agencies, executive leadership, and the board of directors.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to use hands to finger, handle, or feel and reach with hands and arms. The employee frequently is required to stand, walk, and sit. The employee is occasionally required to climb or balance, stoop, kneel, crouch or sit. The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 30 pounds. The employee is occasionally required to ascend and descend one flight of stairs. Specific vision abilities required by the job include close vision, color vision, and ability to adjust focus.

Special Requirements

• Must be able to meet and receive a criminal records clearance, as required by Title XXII, other licensing regulations, and Gracelight practices.
• This position requires frequent driving. A valid California driver license, reliable personal vehicle, current personal auto insurance as required by law, and an MVR sufficient to obtain and reasonably maintain insurability under agency auto liability policies are essential.
• A personal cell phone with reliable service and, if applicable, a data plan to use for business purposes.
• May be required to obtain and maintain First Aid and CPR certification.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is often low, but there are many times when there is a high ambient background noise of phones and multiple conversations. Must be able to screen out the background noise to concentrate on the work at hand.