Care Coordinator

Job Description

Job Description

ABOUT ADOBE  

Adobe Population Health (APH)is a women-owned health solutions company founded in 2018 with a mission of  positively impacting the lives we touch . Headquartered in Phoenix, AZ, with satellite locations across multiple states, APH fosters a culture rooted in inclusivity, human kindness, and high-quality care. 

Recognized by  Inc. 5000as one of America’s Fastest-Growing Private Companies and honored for a fifth consecutive year as a “Best Place to Work” by the  Phoenix Business Journal , APH continues to expand its reach and impact. 

APH partners with health plans, providers, hospitals, and families to deliver tailored programs including case management, in-home and in-clinic wellness assessments, preventative care, transitional care, and social services. As one of the nation’s few fully integrated healthcare organizations, APH delivers comprehensive, coordinated medical and social support through a wide range of specialized service lines. 

With continued growth on the horizon, APH is seeking mission-driven individuals who are passionate about improving health outcomes and supporting those in need. 

POSITION PURPOSE

The Enhanced Care Management (ECM) Care Coordinator serves as the primary point of contact and Care Coordinator for assigned Medi-Cal members enrolled in California's Enhanced Care Management program. The ECM Care Coordinator provides comprehensive, person-centered care coordination services designed to improve health outcomes, address social determinants of health, reduce avoidable emergency department utilization and hospitalizations, and connect members to medical, behavioral health, community, and social support services.

The ECM Care Coordinator collaborates with members, families, caregivers, providers, health plans, and community-based organizations to develop, implement, and monitor individualized

Care Management Plans that address the whole-person needs of members. Services are delivered primarily through community-based engagement and in-person contact whenever possible.

DUTIES & RESPONSIBILITIES

Member Outreach and Engagement

• Conduct outreach and engagement activities for members identified for ECM services.
• Establish trusting relationships with members and their support systems through culturally competent and trauma-informed approaches.
• Engage members primarily through in-person visits and utilize telephonic or virtual methods when appropriate.
• Serve as the member's primary point of contact throughout ECM enrollment.
• Promote member participation in care planning and healthcare decision-making.

Comprehensive Assessment and Care Planning

• Complete comprehensive health and social needs assessments within required regulatory and contractual timelines.
• Identify medical, behavioral health, developmental, oral health, long-term services and supports (LTSS), housing, transportation, food insecurity, and other social needs.
• Develop individualized, person-centered Care Management Plans in collaboration with members, caregivers, and interdisciplinary care teams.
• Regularly review and update care plans based on member progress, changing needs, and clinical recommendations.
• Document strengths, goals, risks, barriers, interventions, and outcomes within the care plan.

Enhanced Care Coordination

• Coordinate services across physical health, behavioral health, specialty care, oral health, LTSS, community support, and social service systems.
• Facilitate communication among providers and multidisciplinary care teams to ensure continuity and integration of care.
• Schedule appointments, arrange transportation, provide appointment reminders, and assist members in overcoming barriers to care.
• Support medication adherence, medication review, and medication reconciliation activities.
• Coordinate care among multiple care management entities to prevent duplication of services.
• Ensure member goals and preferences are communicated to all relevant care team members.

Health Promotion and Member Self-Management

• Educate members regarding chronic disease management, preventive health, and healthy lifestyle choices.
• Encourage members to actively participate in managing their health conditions.
• Identify and strengthen family, caregiver, and community support systems.
• Assist members in developing skills needed to access healthcare and community resources independently.

Transitional Care Management

• Monitor hospital admissions, emergency department visits, skilled nursing facility stays, residential treatment admissions, and other care transitions.
• Conduct transition assessments and develop transition plans to support safe movement across care settings.
• Coordinate post-discharge follow-up appointments and services.
• Complete medication reconciliation activities following transitions of care.
• Implement interventions aimed at reducing avoidable hospital admissions and readmissions.

Family and Caregiver Support

• Engage family members, caregivers, authorized representatives, guardians, and support people as appropriate and permitted.
• Ensure required consents and authorizations are obtained and maintained.
• Educate caregivers regarding care plans, treatment adherence, medication management, and available resources.
• Provide copies of care plans and educate members and caregivers on how to request updates or changes.

Social Determinants of Health and Community Resource Coordination

• Identify social drivers of health impacting member outcomes, including housing instability, food insecurity, transportation barriers, employment, legal concerns, and financial hardship.
• Coordinate referrals to community-based organizations, social service agencies, and Community Supports providers.
• Ensure referrals are completed using a closed-loop process and verify services were received.
• Advocate for members to access necessary community and social support services.

Documentation and Compliance

• Maintain accurate, timely, and complete member records in accordance with Medi-Cal, DHCS, health plan, and organizational requirements.
• Document all member contacts, assessments, interventions, referrals, and care coordination activities.
• Participate in audits, quality reviews, and compliance monitoring activities.
• Ensure all ECM services meet contractual, regulatory, and organizational standards.
• Protect member confidentiality and comply with HIPAA and applicable privacy regulations.

Collaboration and Professional Development

• Participate in interdisciplinary care team meetings, case conferences, utilization reviews, and provider collaboration meetings.
• Attend required ECM, Medi-Cal, compliance, and organizational training programs.
• Collaborate with hospitals, primary care providers, behavioral health providers, specialists, LTSS providers, dental providers, and community organizations.
• Support organizational quality improvement initiatives and population health goals.

Additional Responsibilities

• Perform other duties as assigned to support organizational goals.

SKILLS & QUALIFICATIONS 

• Minimum of two (2) years of experience in case management, care coordination, population health, managed care, or related healthcare setting.
• Knowledge of California Medi-Cal managed care programs and Enhanced Care Management (ECM) model a plus.
• Experience working with high-risk and complex populations, including behavioral health and social determinants of health needs a plus.
• Excellent verbal, written, organizational, and interpersonal communication skills.
• Proficiency with electronic medical records, care management platforms, and Microsoft Office applications.
• Bilingual skills preferred based on regional needs.

EDUCATION, LICENSES, & CERTIFICATIONS

• Bachelor’s degree in social work, human services, public health, psychology or related field required. 
• Master’s degree preferred.
• Certified Case Manager (CCM) certification preferred.

BENEFITS & TOTAL REWARDS

• Paid Training and Onboarding 
• Insurance – Medical, Dental, Vision, and Life
• 401k Plan – 3% match
• Employee Assistance Program
• Tuition Reimbursement
• Continued Education Support
• Mileage Reimbursement (if applicable)
• Referral Bonuses
• Paid Holidays (9 days)
• Paid Time Off (15 days)
• Paid Volunteer Hours 

CHARACTER & COMPETENCIES

• Courage – To have the courage to the right thing at the right time.
• Ownership – To take ownership of every issue you touch.
• Respect – To respect yourself, co-workers, and for those whom you care.
• Excellence – To be excellent in all that you do.
• Diversity - Demonstrates knowledge of EEO policy; Shows respect and sensitivity for cultural differences; Educates others on the value of diversity; Promotes a harassment-free environment; Builds a diverse workforce.
• Ethics - Treats people with respect; Keeps commitments; Inspires the trust of others; Works with integrity and ethics; Upholds organizational values.
• Adaptability - Adapts to changes in the work environment; Manages competing demands; Changes approach or method to best fit the situation; Able to deal with frequent change, delays, or unexpected events.
• Customer Service - Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments.
• Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things.
• Judgement - Displays willingness to make decisions; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions.
• Problem-Solving - Identifies and resolves problems promptly; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem-solving situations; Uses reason even when dealing with emotional topics.
• Professionalism - Tactfully approaches others; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.
• Teamwork - Balances team and individual responsibilities; Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; Able to build morale and group commitments to goals and objectives; Supports everyone's efforts to succeed.

PHYSICAL DEMANDS & WORK ENVIRONMENT

• Occasionally required to stand.
• Occasionally required to walk.
• Continually required to sit.
• Occasionally required to climb, balance, bend, stoop, kneel, or crawl.
• Occasionally required to be exposed to warm or cool spaces.
• Continually required to talk or hear.
• While performing the duties of this job, the noise level in the work environment is usually moderate.
• May occasionally lift and /or move more than 30 pounds.
• Must be able to physically perform the essential duties of the position which include lifting 30 lbs., transporting materials, stooping, kneeling, crouching, reaching, use of hands, balancing, walking, standing, talking, hearing, and typing.

EQUAL EMPLOYMENT OPPORTUNITY  

APH is an Equal Opportunity Employer where all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. 

Adobe Population Health (APH) is a women-owned health solutions company founded in 2018 with a mission of positively impacting the lives we touch. Headquartered in Phoenix, AZ, with satellite locations across multiple states, APH fosters a culture rooted in inclusivity, human kindness, and high-quality care.
Recognized by Inc. 5000 as one of America’s Fastest-Growing Private Companies and honored five consecutive years as a “Best Place to Work” by the Phoenix Business Journal, APH continues to expand its reach and impact.
APH partners with health plans, providers, hospitals, and families to deliver tailored programs including case management, in-home and in-clinic wellness assessments, preventative care, transitional care, and social services. As one of the nation’s few fully integrated healthcare organizations, APH delivers comprehensive, coordinated medical and social support through a wide range of specialized service lines.
With continued growth on the horizon, APH is seeking mission-driven individuals who are passionate about improving health outcomes and supporting those in need.

Company Description

Adobe Population Health (APH) is a women-owned health solutions company founded in 2018 with a mission of positively impacting the lives we touch. Headquartered in Phoenix, AZ, with satellite locations across multiple states, APH fosters a culture rooted in inclusivity, human kindness, and high-quality care. \r\nRecognized by Inc. 5000 as one of America’s Fastest-Growing Private Companies and honored five consecutive years as a “Best Place to Work” by the Phoenix Business Journal, APH continues to expand its reach and impact. \r\nAPH partners with health plans, providers, hospitals, and families to deliver tailored programs including case management, in-home and in-clinic wellness assessments, preventative care, transitional care, and social services. As one of the nation’s few fully integrated healthcare organizations, APH delivers comprehensive, coordinated medical and social support through a wide range of specialized service lines. \r\nWith continued growth on the horizon, APH is seeking mission-driven individuals who are passionate about improving health outcomes and supporting those in need.