ECM Lead Care Manager

Mercy House; Santa Ana (CA); On-site; USD 65,904,000 - 71,635,000; Full time

Benefits offered by this job

Flexible medical coverage

Dental/vision/insurance options

Paid time off (PTO)

FSA

EAP

403(b) with up to 3% match

Mileage reimbursement

Referral program

Professional growth opportunities

On-the-job training

Job summary

Mercy House is seeking an Enhanced Care Management (ECM) Lead Care Manager to coordinate medical and non-medical services for clients experiencing homelessness or at risk of homelessness in Santa Ana, CA.

You will maintain a caseload, engage members, coordinate appointments, and advocate for patient-centered care with a focus on social determinants of health. Travel to client sites is required.

Qualifications

• Bachelor’s Degree in Social Work (or related field) required; equivalent experience considered.
• 2+ years direct life experience with homeless, low-income, diverse populations are welcome to apply.
• Valid CA driver’s license, proof of insurance, reliable vehicle for home visits.

Responsibilities

• Maintain a caseload of 17–25 individuals and conduct Health Needs Assessments and Care Plans.
• Engage, enroll, and help address barriers to ECM services.
• Coordinate transportation and accompany members to appointments as needed.
• Advocate for members with healthcare professionals and hospitals; assist with discharge planning.
• Collaborate with hospitals, behavioral health and LTSS providers to coordinate care.
• Monitor treatment adherence and provide health promotion and self-management training.
• Document progress and report needs to the multidisciplinary team.

Skills

Outreach & Engagement

Care Planning

Care Coordination

Health Promotion

Transitional Care

Member Education

Family Education

Social Services Coordination

Spanish (valued)

Education

Bachelor’s Degree in Social Work or related field

Tools

Microsoft Word

Microsoft Outlook

Microsoft Excel

PowerPoint

Job description

Status: Full-Time, Non-ExemptPay: $23.00-$25.00/hourSchedule: 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 optionsVoluntary dental, vision, life, accident, critical illness, and hospital insurancePaid Time Off (PTO)Flexible Spending Account (FSA)Employee Assistance Program (EAP)403(b) retirement plan with up to 3% employer matchingPaid on-the-job training and orientationMileage reimbursementEmployee referral programOpportunities for professional growth and advancementJob 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 DeliveryMaintain 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 goalsEngage, outreach, and enroll eligible ECM members in services and help address barriersOffer services where the member lives, seeks care, or finds most easily accessible, within CalOptima Health guidelinesSupport 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 treatmentAccompany members on office visits as needed and according to CalOptima Health guidelinesAdvocate on behalf of the member with healthcare professionals and work with hospital staff on discharge plansCollaborate 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 careUse motivational interviewing and trauma-informed care practicesMonitor treatment adherence (including medication)Provide health promotion and self-management training to enrolled ECM membersReport ECM patient progress, concerns, and needs to the multidisciplinary team to improve patient careOther duties may be assigned or modifiedTeam/Staff RelationsWork as a Mercy House team member with all staff and volunteers to implement the mission and core values of the agencyAttend regular internal and external agency meetingsWork as part of a team to plan and develop resident programsWork in a team environment, fast-paced environment, be flexible, adaptable to sudden changes, trustworthy, reliable, and empatheticCommunicate effectively with diverse populationsAdministrationKeep accurate, up-to-date documentation on all clients, including but not limited to Health Needs Assessments and Care PlansAssist with all data collection systemsAssure deadlines are metUtilize computers and appropriate software (e.g., Microsoft Word, Outlook, Excel, PowerPoint) and/or specific systems applicable to the positionRespond to calls and emails in a timely mannerPerform tasks independently and prioritize workloadKnowledge of:Confidentiality and the legal and ethical issues pertaining to case managementEffective documentation and guidelinesRequirements:Education and ExperienceBachelor’s Degree in Social Work (or related field) with experience working in chemical health, mental health, and co-occurring disorders are preferredPersons with less than a BA/BS degree but with at least 2 years of direct life experience working with long-term homeless, low-income, and diverse populations and have a working knowledge of mental health and addiction issues are welcome to applyPreferred skills related to outreach and engagement, care planning, care coordination, health promotion, transitional care support, member and family education, and social services coordinationPreferred minimum of 1 year of experience in care coordination and case management for the following populations: Individuals/Families experiencing homelessness, Individuals at risk for avoidable hospital stays (High Utilizers), Individuals with Serious Mental Health and/or SUD, Adult Nursing Facility Residents Transitioning to the Community, Adults with intellectual or developmental disabilitiesExperience with HMIS Data Entry/CalOptima Health strongly preferredPreferred experience with Housing First and Harm-Reduction strategies, Motivational Interviewing, Patient-Centered and Trauma-Informed Care, Crisis Intervention & Prevention strategiesPreferred experience in engaging and assisting individuals/families with acute mental illness & substance use to access/navigate health care as well as other needed servicesKnowledge of how to use Microsoft programs and computer literacy are requiredGeneralA 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 othersDependability, responsibility, and the ability to communicate effectively and respectfully are mandatory skillsFluency in Spanish is of significant valuePhysical RequirementsAbility to lift items weighing up to 50 poundsProlonged periods of sitting at a desk and working on a computer