ECM Case Manager - (SUD Population Focus)

Via Care Community Health Center; Los Angeles (CA); On-site; USD 65,000 - 90,000; Full time

Job summary

Via Care Community Health Center seeks an ECM Case Manager to deliver whole-person, member-centered care management for Medi-Cal members with complex health and social needs, with a focus on those affected by substance use disorders. The role emphasizes care coordination, advocacy, and linkage to housing, behavioral health, and community services.

The position involves outreach, assessments, care plan development, coordination across medical and social services, and thorough documentation in

Qualifications

• Understanding trauma-informed approaches and cultural responsiveness.
• Experience coordinating services across healthcare and social supports.
• Ability to engage diverse populations and stakeholders.
• Knowledge of HIPAA and healthcare privacy requirements.
• Familiarity with Electronic Health Records (EHR) systems.

Responsibilities

• Engage ECM-eligible members through field-based and community outreach.
• Complete comprehensive assessments of health, housing, and social needs.
• Develop individualized care plans reflecting member goals.
• Coordinate medical, behavioral health, housing, and community services.
• Support transitions of care after hospital or treatment events.

Skills

Trauma-informed care

Care coordination

Community outreach

Patient advocacy

HIPAA compliance

EHR proficiency

Tools

EHR systems

Job description

Job SummaryThe ECM Case Manager provides whole-person, member-centered care management services to Medi-Cal members with complex health and social needs, with a primary focus on individuals impacted by substance use disorders (SUD). Through outreach, engagement, assessment, care planning, coordination, and follow-up, the ECM Care Manager supports members in accessing medical, behavioral health, housing, and community-based services that improve health outcomes and overall well-being. The ECM Case Manager does not provide substance use counseling, psychotherapy, or clinical treatment services. Instead, the role focuses on care coordination, service linkage, advocacy, and member engagement to help individuals navigate complex systems of care.

Duties And Responsibilities

Member Engagement and Outreach

• Conduct field-based, community-based, and telephonic outreach to engage ECM-eligible members.
• Establish trusting relationships with members through a trauma-informed and culturally responsive approach.
• Meet members where they are, including homes, shelters, treatment facilities, hospitals, community settings, and other approved locations.
• Maintain ongoing contact with members according to ECM program requirements.

Assessment and Care Planning

• Complete comprehensive assessments of members' physical health, behavioral health, substance use, housing, social support, and resource needs.
• Develop individualized care plans that reflect member goals, strengths, and priorities.
• Monitor progress toward care plan goals and update plans as needed.
• Identify barriers to healthcare access and engagement.

Care Coordination

• Coordinate services across medical, behavioral health, social service, and community-based systems.
• Facilitate communication among providers, health plans, community organizations, and support networks.
• Assist members in scheduling and attending appointments.
• Support transitions of care following emergency department visits, hospital admissions, residential treatment episodes, incarceration, or other significant life events.
• Ensure members receive appropriate follow-up services and supports.

SUD-Focused Care Management

• Support individuals with substance use disorders through engagement, education, advocacy, and resource navigation.
• Coordinate referrals and warm handoffs to substance use treatment and recovery support programs.
• Assist members in accessing:
  • Medication-Assisted Treatment (MAT)
  • Outpatient treatment programs
  • Residential treatment services
  • Recovery support services
  • Behavioral health services
  • Peer support programs
• Promote harm reduction and recovery-oriented principles.
• Encourage member participation in services while respecting individual choice and readiness for change.

Community Supports Coordination

• Assist members in accessing CalAIM Community Supports and other community resources.
• Coordinate housing-related services including housing navigation, tenancy support, and housing stabilization resources when appropriate.
• Support access to transportation, food resources, public benefits, and community-based services.
• Advocate for members within healthcare, housing, and social service systems.

Documentation and Compliance

• Maintain accurate, timely, and complete documentation in electronic health records and care management systems.
• Document assessments, care plans, member contacts, referrals, and outcomes according to organizational and regulatory requirements.
• Participate in case conferences, interdisciplinary care team meetings, and quality improvement activities.
• Adhere to CalAIM ECM, Medi-Cal Managed Care, HIPAA, and organizational requirements.