ECM Lead Care Manager

At Episcopal Community Services (ECS), employees work with participants who may be experiencing homelessness, behavioral health conditions, substance use challenges, and other difficult life circumstances. While this work is meaningful and mission-driven, it can at times be stressful, demanding, or unpredictable. Employees are expected to exercise sound judgment, remain aware of their surroundings, follow established safety, communication, and de-escalation procedures, participate in all required trainings, and promptly report incidents, threats, injuries, or unsafe conditions, in accordance with ECS policies and procedures.

This position is a fully onsite, client-facing role that requires in-person interaction and direct service delivery to participants at ECS program locations. Due to the essential nature of the duties and the need for consistent in-person engagement with clients, remote work or work-from-home arrangements are not available for this position.

P OSITION SUMMARY

The Enhanced Care Management (ECM) Lead Care Manager is responsible for improving care coordination, improving health outcomes, enhancing satisfaction, and reducing unnecessary healthcare utilization. ECM is a comprehensive, patient-centered approach to healthcare that aims to improve outcomes for high-need populations. This involves the coordination of medical, behavioral, and social services to address the full range of patient needs, focusing on those with complex and chronic conditions. This program is designed to optimize care delivery, reduce unnecessary hospitalizations, and improve the overall quality of life for individuals served. The intention of our services is to help people who have not been able to access needed Housing supports, Mental Health/Substance Abuse treatment, and other community resources to help minimize recidivism. The role of the ECM Lead Care Manager is to facilitate multi-disciplinary team meetings and create a supportive network of services and resources for the client. The Lead Care Manager position requires experience in housing services, case management, and a passion for providing advocacy and in vivo support to individuals navigating complex social challenges.

PRIMARY DUTIES AND RESPONSIBILITIES

• Conduct outreach to identify and engage eligible in ECM services, using multiple strategies and modalities for engagement.
• Interview and conduct assessments of clients' needs, including medical, behavioral, and social factors.
• Develop, implement, and monitor personalized care plans in collaboration with clients, their families, healthcare providers, and community resources.
• Monitor and evaluate the effectiveness of care plans and making adjustments as needed to client goals.
• Serve as the primary point of contact for the client, relevant family members, and other supports.
• Organize and facilitate the client's multi-disciplinary care team.
• Coordinate care across multiple providers and services, ensuring seamless integration of medical and social care.
• Act as a client advocate, ensuring the client's needs and preferences are central to care decisions.
• Facilitate regular team meetings to review patient cases, address challenges, and share successes.
• Travel locally to deliver services to clients in the community where they live, work, or frequent.
• Document services in the appropriate Electronic Health Record within 72 hours of each service and in compliance with agency policy, as well as contractual, state, and federal regulations.
• Coordinate and link the client to all needed resources and community services.
• Maintained concise and comprehensive case records on all participants seeking services.
• Provide accurate daily and monthly documentation and case notes as per funding source guidelines.

• Attend workshops, meetings, and trainings as requested by supervisor.

Performs other related duties as assigned.

REQUIRED QUALIFICATIONS

• Bachelor's degree in behavioral health, human services, public health, or a related field strongly preferred.
• Two years' experience in housing navigation, social services, or a related field with a focus on care management.
• Community Health Worker certification preferred but not required.
• Strong understanding of the housing sector, including affordable housing and fair-housing laws.
• Excellent coordination and networking skills to work effectively with a variety of community partners and service providers.
• Strong advocacy and interpersonal skills, with the ability to work compassionately with diverse populations
• Problem-solving skills and the ability to think critically to overcome housing barriers.
• Ability to change direction as priorities shift.
• Ability to relate to diverse populations in a culturally sensitive way.
• High level adaptability and the ability to quickly integrate into different teams while maintaining program fidelity and compliance.
• Knowledge of local social services and other community resources for underserved populations and severely low-income individuals and families.
• Ability to professionally work under pressure with difficult or temperamental participants and staff.
• Must show patience, compassion, and empathy to the participants that we serve.
• Must possess excellent charting, recordkeeping, and professional writing skills for daily documentation.
• Must be able to quickly assess and respond to a variety of situations, including medical emergencies, psychiatric emergencies, conflict resolution, de-escalation interventions, as well as other types of crises.
• Computer skills and moderate experience using Microsoft Outlook, Word, and other MS Office applications is required.
• Strong interpersonal skills, a team approach, and the ability to communicate effectively both orally and in writing are essential.
• Demonstrated cultural competency in working with diverse, underserved, and the ability to communicate in Spanish is desirable. Bi-lingual positions (if open) pay a 5% premium!
• Demonstrates and supports a culture of diversity, equity, inclusion and belonging.
• Great collaborator with the ability to maintain professional, respectful, honest, and calm interactions with residents, staff, and outside partners is required.
• Must be able to work as part of a multi-disciplinary team.
• Must be comfortable facilitating groups and hosting events and activities.
• Must be committed to the mission and values of Episcopal Community Services.

OTHER

• Must secure finger image screening and annual TB screening.
• Must be able to travel to various sites, possess a driver's license and have a clean DMV record.
• Must be able to meet physical requirements of the position which may include long periods at a desk and/or computer workstation, and lifting of up to 25 lbs.

MISSION ESSENTIAL

• Demonstrate behavior that supports the organization's mission, vision, and values.
• Promote open communication and help create an environment where doing the right thing is expected and supported, not feared.
• Adhere to all company and program best practices, policies and procedures.
• Communicate effectively and model integrity, fairness, and ethical business practices.

ECS offers industry leading healthcare benefits to support your

physical and mental well-being.

ECS will consider for employment qualified applicants with arrest and conviction records as consistent with San Francisco's Fair Chance Ordinance.

ECS values a workplace where every individual is respected, supported, and given equal opportunity to thrive. We are an equal opportunity employer dedicated to creating a welcoming and inclusive environment for all.