ECM, SM - Care Manager I

CalAIM, a Department of Health Care Services (DHCS) initiative, aims to improve Medi-Cal recipients' quality of life and health outcomes through system reforms. It introduces Enhanced Care Management (ECM), a statewide Medi-Cal Managed Care Plan (MCP), that offers person-centered, community-based highest care management tier within the Medi-Cal MCP Population Health Management continuum. Participating members are assigned a Care Manager who will meet them wherever they are: on the street, in a shelter, in their provider’s office, or at home to coordinate their health-related care and services, ensuring holistic approach to their well-being. In addition, ECM offers community-based services to address health-related social needs to help members live healthier lives and avoid more costly levels of care. Some examples include support to secure and maintain housing, access to medically tailored meals for short-term recovery, and various other community-based services. The Care Manager I facilitates care by connecting clients with suitable services to meet their needs, including physical and mental health, substance use issues, employment (both residential and outpatient), legal concerns, housing, community resources, and aftercare. This in-person and field-based role involves working directly with members in diverse settings such as their homes, homeless encampments, service provider locations, and other areas requiring outreach, therefore, reliable transportation is required. KEY RESPONSIBILITIES Enrollment and Engagement Identify eligible individuals from various locations for enrollment into ECM. Use multiple strategies for engagement (in-person meetings, mail, email, texts, telephone, community outreach). Client Care Activities Organize client care activities according to Managed Care Plan (MCP) requirements. Share information with the client’s multi-disciplinary care team. Implement activities identified in the MCP. Provide support to engage clients in their treatment including medication review, appointment scheduling, transportation coordination, and addressing barriers to engagement. Assist with intake by completing required assessments. Connect clients to benefits, healthcare services, employment, housing, and community resources. Monitor client’s progress toward achieving treatment plan goals and provide treatment plan input. Care Coordination Maintain regular contact with all providers involved in the client’s care team. Ensure continuous and integrated care among all service providers. Refer and follow up with primary care, mental health, substance use disorder treatment, and necessary community-based services. Collaborate with clients and their families for community reintegration. Collaborate with outside agencies to obtain needed community resources (housing, sober livings, substance abuse recovery agencies, medical facilities, employment/education agencies, DPSS, DMV or other needed resources). Communicate collaboratively with all members of the behavioral health team. Field-Based Responsibilities Meet ECM clients at their physical locations and cater to their individual needs. Conduct care management activities in locations most attainable and desirable for clients. Have access to office space for care management activities and attend required training and meetings as needed. Submit mileage for field-based care management activities for reimbursement. Administrative Duties Write and complete all progress notes within 24 hours of service delivery. Write client progress letters and court reports. Actively participate in assigned Group Supervision, agency, and team meetings. Participate in training opportunities and complete assigned training in a timely manner. QUALIFICATIONS Education, Certification, or Licensure High school diploma or equivalent required. Valid First Aid and CPR certification or ability to obtain within 30 days of hire. Valid California driver’s license and access to registered and insured transportation. Experience 2 years of care management experience. Experience working with clients experiencing acute withdrawal from substances. Desired Experience working with the criminal justice population preferred. Experience working with Medi-Cal, Medi-Care, and private medical insurance plans preferred. Experience providing trauma-informed services preferred. PHYSICAL REQUIREMENTS In an 8-hr workday, employee is required to perform work: Sitting 4 Hrs Standing 2 Hrs Walking 2 Hrs Driving Frequently