ECM Case Manager (Clinical)

SUMMARY: Serves as a licensed or registered clinical Lead Care Manager in Front St.'s Enhanced Care Management (ECM) program. Delivers comprehensive, primarily in-person care management and care coordination to Medi-Cal members with complex medical, behavioral health, and social needs, meeting Central California Alliance for Health (CCAH) and DHCS requirements. Services are provided within the scope of the employee's license or registration and are billed as Clinical ECM Services. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential job functions.

ESSENTIAL DUTIES AND RESPONSIBILITIESMust be able to perform each essential job function satisfactorily.

 Direct Care and Clinical Case Management

1. In a culturally competent manner will provide services to all participants without regard to race, color, creed, national origin, marital status, sexual orientation, age, sex, religion, and handicap or payment status.
2. Serve as Lead Care Manager for an assigned caseload of ECM members, coordinating their physical health, behavioral health, substance use, dental, and social services.
3. Conduct and document outreach to engage eligible members, primarily in person where members live, seek care, or prefer to access services.
4. Complete the ECM comprehensive assessment within the scope of your license or registration, identifying medical, behavioral health, substance use, and social needs.
5. Develop, update, and monitor each member's Care Management Plan with the member and their support persons, with review and sign-off by the Clinical Director.
6. Deliver ECM services primarily in person. Use telehealth only to supplement in-person contact, or when it matches the member's stated preference.
7. Provide transitional care support after hospital, emergency department, or facility discharge, including coordination with the discharging facility and follow-up appointments.
8. Provide health promotion and self-management education, and address barriers to care.
9. LVNs and RNs: perform medication reconciliation, medication education, and health monitoring within scope of practice and under the direction of the Lead RN or a physician.
10. Behavioral health clinicians (LCSW, LMFT, LPCC, ASW, AMFT): provide behavioral health and substance use screening and care coordination within the scope of license or registration and under required supervision.
11. Refer members to community and social supports, including housing and Community Supports, and follow up to confirm services were received.
12. Help members keep their Medi-Cal eligibility, including documentation for any exemptions from work or reporting requirements.
13. Reassess members regularly. Notify the ACE Team Manager when a member meets care plan goals, is ready for a lower level of care, or cannot be reached despite documented attempts.
14. Inform participants of their personal rights, responsibilities, and Company's grievance procedures. Ensure that services are compatible with participants' freedom of choice.
15. Adhere to ethical and professional standards of practice, including maintaining client confidentiality and respecting cultural diversity.
16. As needed transport participants to appointments, outings etc.

Teamwork and Collaboration

1. Maintain cooperative and professional working relationships and communications.
2. Collaborate with interdisciplinary team members, primary care, behavioral health, and hospital partners to coordinate care and optimize outcomes.
3. Participate in multidisciplinary care team conferences with the member's other providers.
4. Attend clinical supervision as required by your license or registration and Front St. policy.
5. Meet program outcome expectations in collaboration with CCAH.
6. Participate in regular team meetings and training to coordinate care and optimize outcomes.
7. Give input to management on improving the quality of programs and assist in monitoring program effectiveness and participant satisfaction.

 Reporting and Documentation

1. Mandated to report any “suspected abuse of dependent adults and elders” directly to Law Enforcement, Adult Protective Services, Ombudsman, or Community Care Licensing.
2. Document every ECM contact in the electronic health record on the date of service, with accurate start and stop times, modality (in person or telehealth), and the service provided, consistent with CCAH and DHCS requirements.
3. Keep clear, accurate, and professional records that support every billed unit. Records are subject to CCAH post-payment audit.
4. Meet caseload, productivity, and member contact standards set by the program.
5. Submit timely and accurate billing data and other requested reports.

Qualifications

 Education and/or Experience

1. Must hold one of the active California clinical credentials listed under Eligible Clinical Credentials below.
2. One year of experience serving adults with serious mental illness, substance use disorders, chronic health conditions, or homelessness.
3. Experience documenting services for Medi-Cal billing preferred.

 Eligible Clinical Credentials

1. Licensed Vocational Nurse (LVN) – Board of Vocational Nursing and Psychiatric Technicians
2. Registered Nurse (RN) – Board of Registered Nursing
3. Licensed Clinical Social Worker (LCSW) – Board of Behavioral Sciences (BBS)
4. Licensed Marriage and Family Therapist (LMFT) – BBS
5. Licensed Professional Clinical Counselor (LPCC) – BBS
6. Associate Clinical Social Worker (ASW) – BBS registration, license-waived [Pending CCAH confirmation]
7. Associate Marriage and Family Therapist (AMFT) – BBS registration, license-waived [Pending CCAH confirmation]

Credential must be active and in good standing for the duration of employment. Employee must also meet DHCS provider screening and enrollment requirements. Associates must maintain BBS registration and required supervision (contracted LCSW supervision for ASWs).

 Knowledge

1. Knowledge of CalAIM Enhanced Care Management requirements and Medi-Cal documentation standards.
2. Experience assisting with housing navigation/community outreach and supervision of participants.
3. Knowledge and conformity to all applicable HIPAA, OSHA, state and local laws, rules and regulations including Department of Health Care Services.
4. Comprehension of the implementation of a Trauma Informed approach to participant care.

 Language Skills

1. Read, speak, write and understand English well enough to follow and share the regulations, requirements and communications for providing care to participants.
2. Able to effectively present information and respond to questions.
3. Bilingual English/Spanish preferred.

 Mathematical Skills

1. Calculate figures and amounts such as discounts, proportions, and percentages associated with completing the requirements of the position.

 Reasoning Ability

1. Ability to carry out written, oral, or diagramed instructions.
2. Competent in dealing with problems involving several variables in different situations.

 Other Skills and Abilities

1. Timely complete tasks, meet deadlines, problem solve, and coordinate numerous activities. Adjust tasks in accordance with changing deadlines and priorities.
2. Maintain cooperative and professional working relationships.
3. Adequate computer skills to utilize e-mail, word processing and needed programs.

 Additional Requirements

1. Must be 21 and accepted by the Company’s vehicle insurance.
2. Cleared by the Department of Justice and County.
3. Maintain an active license or registration. Notify your supervisor immediately of any change, restriction, or formal charge affecting it.
4. May be required to serve on company committees.
5. Complete all annual training requirements as mandated by Santa Cruz County and Front St. Policies.
6. Attend mandated meetings and training; fulfill all coursework and training hours required.
7. Work in a safe and acceptable manner, following established safety procedures.

 Physical Demands: Must be met to successfully perform the essential job functions.

1. Regularly required to talk, hear, and sit, stand for extended periods of time.
2. Frequently required to reach with hands, arms, stand, walk, stoop, and may occasionally be required to kneel, crouch, crawl or lift up to 25 pounds.
3. Be physically, mentally and occupationally capable of performing assigned task.

 Work Environments: Employee may encounter while performing essential job functions.

1. Noise level is usually low to moderate.
2. Possible contact with hazardous and caustic household cleaning chemicals.
3. The actions of clients may be unpredictable. Staff may be verbally assaulted and at times may be physically injured.