ECM Lead Care Manager

ECM Lead Care ManagerExpected Hourly Pay Rate: $27.00Work where your work matters. Work at CCRC.CCRC prides itself as a workplace of choice for passionate talent, driven by our mission to cultivate child, family and community well-being. Whether the position works directly with the public or supports our programs, every position is vital to our mission's success and reputation as a leader. We are not your typical non-profit. We are 900+ people strong and growing!General Summary: Under general direction, the ECM Lead Care Manager serves as the primary point of contact for Managed Care Plan (MCP) members and their support systems, coordinating care across clinical, behavioral health, and community-based services.The Lead Care Manager provides whole-person care management for members within the Birth Equity population of focus, including pregnant and postpartum individuals and families with infants up to 12 months old. This role emphasizes engagement, assessment, care planning, resource linkage, and collaboration with multidisciplinary care teams to address medical, behavioral, and social determinants of health.This is a full-time, field-based position that includes in-person, community-based, virtual, and telephonic engagement within the service area.Approximately up to 40% of local travel is required to support in-person, community-based, and healthcare-setting service delivery.Essential Duties And ResponsibilitiesWithin a field-based environment, this position will perform the following responsibilities:Care Management and Coordination of Community Services 55%Partner with Licensed Clinician to conduct and coordinate comprehensive multidisciplinary assessments across physical health, behavioral health (including trauma and substance abuse), oral health, and social support needs, including identifying appropriate referrals and linkages to community-based services.Develop, implement, and maintain individualized Care Plans/Action Plans that guide ongoing care coordination, service delivery, and goal tracking.Serve as the primary point of contact for members and designated caregivers, ensuring consistent communication and coordination across the multidisciplinary care team.Ensure members are connected to a primary care provider and have an identified Authorized Representative (AR) and/or caregiver, and coordinate advocacy efforts with healthcare providers and community partners, with member consent.Deliver services where the member lives, seeks care, or finds most easily accessible, including office-based, telehealth, or field-based servicesConnect members to non-clinical social and other health-related services, including coordinating transportation and interpreting services and support member engagement and access to services by providing health education and coaching, accompanying members to appointments when appropriate, and coordinating transportation and interpreting services as needed.With permission, coordinate/advocate on behalf of client with health care professionals (e.g., PCP)Utilize evidence-based practices, including Motivational Interviewing, Harm Reduction techniques, and Trauma-Informed Care principles, to engage members, support goal attainment, and promote self-management skills.Coordinate Transitional Care Planning in collaboration with hospitals, emergency departments, and other institutional providers, including monitoring member progress, updating goals, and conducting pre-graduation assessments to support appropriate transition or discharge from ECM services.Provide health promotion services to encourage and support members to make lifestyle choices based on healthy behavior, with the goal of motivating members to successfully monitor and manage their health.Complete all required documentation accurately and within established timeframes by the individual action plan, and adhere to all legal, ethical, and contractual requirements related to ECM services, including HIPAA, confidentiality, and recordkeeping standards.Member Engagement, Screening & Assessment 15%Conduct outreach, engagement, and ongoing follow-up with MCP members and identified support persons to support enrollment, participation, and retention in ECM services.Complete required screenings and assessments (e.g., ACEs, PHQ-9, GAD-7, clinical and non-clinical assessments) and document results per program and MCP requirements.Identify barriers to care (e.g., housing instability, domestic violence, behavioral health needs, DCFS involvement) and integrate findings into individualized care planning and services coordination.Community Outreach 25%Conduct outreach and engagement activities to support enrollment of eligible Managed Care Plan members into the ECM program, utilizing methods such as phone outreach, mailed information, field visits, and other engagement activities as defined by the ECM provider.Develop and maintain collaborative relationships with healthcare providers, social service agencies, and community organizations to identify eligible members and facilitate appropriate referrals to ECM services.Meetings and Trainings 5%Attend required staff, team, and interdisciplinary care team meetings and supervisionAttend training as assigned (e.g., ACEs Certification).Attend mandatory agency, provider-focused training, webinars, conferences, and technical assistance meetings (e.g. ACEs Certification)Maintain ongoing professional development, up-to-date perinatal and maternal health, mental health education, and related certifications as required.Job SpecificationsMinimum RequiredEducation and Experience (one of the following):Bachelor's degree with two (2) years of relevant case management or care coordination experience; ORAssociate of Arts degree with three (3) years of relevant experience; ORHigh School Diploma or equivalency with four (4) years of relevant experience.Experience:Minimum of two (2) years' experience working with pregnant individuals, children, and/or parents/caregivers.At least two (2) years' experience coordinating services across healthcare, behavioral health, and community systems.Professional/Technical Certifications: n/aTechnical Requirements:Computer skills; including web browsing, e-mail, data entry, and word processing. Proficient in Zoom, Adobe Suite, and Windows-based programs: Microsoft Outlook, Word, Excel, Teams, and PowerPoint.Bilingual Required: n/aTravel: Approximately up to 40% local travel required to support in-person, community-based, and healthcare-setting service delivery. Staff members driving on behalf of CCRC may choose to drive a CCRC vehicle or own vehicle and must meet requirements to be an approved driver including holding and maintaining current auto insurance, current California Driver's License and DMV clearance required.Work Schedule: Full-time. Typically, M-F, with the ability to work at times a non-traditional work schedule including early mornings, late evenings, and weekends.Work Environment: Field-Based. Combination of working in an office, working from home, and working in the community. Includes virtual visits, family homes, hospitals, parks, and other locations in the community as required.Background & Health Clearance Requirements:Background check required. As a grant-funded Agency supporting Children and Family Services, CCRC conducts background checks commensurate with the role to verify candidate qualifications (criminal history, employment history / experience, education, reference checks) and ensure grant compliance. Specific roles may have additional verification / clearance to the standard background check as part of the recruitment and selection process, including:Live Scan Clearance / DOJ Fingerprinting: For positions working directly with the public in a child/ community care or child / community care adjacent setting (CA Health and Safety Code Section 1596.871 and/or Head Start Program Performance Standards 1302.90).Health Clearance: For positions working directly with the public in a child/ community care or child / community care adjacent setting or working with "at risk" populations, CA Code of Regulations Title 22, §101216, CA Health and Safety Code 1596.7995, and/or Head Start Program Performance Standards 1302.93)MVR / DMV clearance in accordance with CCRC's liability insurance provisions: For positions where driving is required.Child Development Permit: For positions working in an educational capacity (California Education Code Sections 44242.5, 44340, and 44341) CPR / Pediatric CPR certification: For certain identified positions working directly with the public in a child/ community care or child / community care adjacent setting (CA Health & Safety Code 1596.865 – 1596.866