ECM Clinical Care Manager

ECM Clinical Care Manager

Amity Foundation, an internationally acclaimed Teaching, and Therapeutic Community is seeking compassionate and enthusiastic individuals with a desire to teach, learn and join our community.

Amity Foundation is a safe place where people can change in an environment that fosters trust; where new values can be formed; responsibility developed, and lasting relationships built. Amity is dedicated to the inclusion and habilitation of people marginalized by addiction, homelessness, trauma, criminality, incarceration, poverty, racism, sexism, and violence. Amity is committed to research, development implementation, and dissemination of information regarding community building.

The Enhanced Care Management (ECM) Clinician is responsible for member 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 member needs, focusing on those with complex and chronic conditions.

The role of the ECM Clinical Case Manager provides integrated clinical and case management services to justice-involved individuals enrolled in Enhanced Care Management (ECM), with a primary focus on in-custody engagement within Orange County jail facilities and post-release community reintegration. This role delivers in-person assessments, pre-release planning, and clinical coordination inside the three Orange County jail facilities, while maintaining continuity of care through post-release case management, clinical touchpoints, and linkage to services in the community.

The Clinical Case Manager operates as part of a multidisciplinary Orange County care team, supporting individuals with complex medical, behavioral health, substance use, and social needs. The goal is to improve health outcomes, reduce recidivism, and support successful transitions to stable housing, treatment, and long-term community integration.

This position requires the ability to work effectively in secure custodial environments and field-based settings across Orange County, while adhering to all facility regulations and maintaining a high level of clinical and professional standards.

Essential Duties:

• Interview and conduct clinical assessments of member's needs, including medical, behavioral, and social factors.
• Develop, implement, and monitor personalized care plans in collaboration with members, their families, healthcare providers, and community resources.
• Conduct outreach to identify and engage eligible in ECM services, using multiple strategies and modalities for engagement.
• Operate as part of the member's multi-disciplinary care team.
• Facilitate regular team meetings to review patient cases, address challenges, and share successes.
• Travel locally to deliver services to members in the community where they live, work, or frequent.
• Document services in the agency's Electronic Health Record within 72 hours of each service and in compliance with agency policy, as well as contractual, state, and federal regulations.
• Provide accurate daily and monthly documentation and case notes as per funding source guidelines.
• Attend workshops, meetings, and trainings as requested by supervisor.
• Provide in-person pre-release case management services within Orange County jail facilities, including conducting assessments, initiating care plans, and engaging members before release.
• Complete and maintain clearance for county jail access, including passing all required background checks and complying with facility-specific rules and regulations at all times.
• Adhere to all county jail visiting policies, procedures, and security protocols, demonstrating professionalism and compliance in a custodial setting.
• Deliver comprehensive pre-release planning, including development of individualized care plans, coordination of benefits, and linkage to housing, medical, and behavioral health services.
• Conduct in-person outreach, engagement, and ECM enrollment within Orange County jail facilities.
• Complete comprehensive biopsychosocial, Health Risk Assessments (HRA) to identify medical, behavioral health, and social service needs.
• Collaborate with custody staff and the multidisciplinary OC care team to coordinate care and ensure alignment of services.
• Deliver clinical interventions, including brief counseling, crisis intervention, and stabilization support as needed.
• Participate in case conferencing and provide clinical insight and recommendations for complex cases.
• Ensure compliance with all jail clearance requirements, security protocols, and visiting regulations.
• Provide post-release follow-up and transition support, ensuring continuity of care from custody to community.
• Conduct post-transition touchpoints, including wellness checks and ongoing care coordination.
• Link clients to housing, medical care, mental health services, substance use treatment, and benefits (SSI, Medi-Cal, etc.).
• Schedule and coordinate medical and behavioral health appointments.
• Provide or coordinate transportation upon release, including transfers to housing placements, shelters, or family residences.
• Support long-term stabilization goals, including housing retention and reduced recidivism.
• Coordinate services across medical, behavioral health, and social service systems.
• Maintain accurate and timely documentation in the Electronic Health Record (EHR) within required timelines.
• Maintain detailed case records and complete all documentation in compliance with agency, county, state, and federal guidelines.
• Provide clinical consultation and support within the care team.
• Deliver crisis intervention services and de-escalation support when needed.
• Collaborate with mental health providers, probation, Parole housing partners, and internal teams.
• Support adherence to trauma-informed care and therapeutic community principles.
• Participate in trainings and contribute to maintaining fidelity to clinical models.
• Attend multidisciplinary team meetings, trainings, and supervision sessions.
• Support program development and implementation of clinical strategies.
• Assist in identifying and addressing system-level barriers to care.
• Perform other duties as assigned.

Education and Experience:

Required:

• MFT or MSW with experience working with mental health, substance abuse, homeless, and/or re-entry populations. Experience with crisis intervention, hospitalization, psychiatry, and mental health diagnosis.
• Registered with the Board of Behavioral Science BBS

Preferred:

• Previous Clinical experience working with individuals recently released from jail or prison a plus. Previous Supervisory experience.
• Experience providing services inside correctional facilities
• Knowledge of reentry systems, benefits navigation, and housing resources
• Mental health and/or substance use treatment
• Homeless or high-acuity populations

Must be able to pass a comprehensive background check and obtain clearance to enter and work within Orange County jail facilities.

Experience working with justice-involved or formerly incarcerated populations strongly preferred.

Comfortable working in both secure custodial environments and community-based field settings.

Strong communication and interpersonal skills, capable of building relationships with members, families, team members, and community partners.

Understand various ethnic and socioeconomic backgrounds within a multicultural environment.

Knowledge of how to administer assessments, substance abuse counseling, reentry services, and case management within a culturally diverse population, preferably with both men and women.

This position requires local travel and the ability to navigate public transportation with members.

Required to use company vehicle as well as personal vehicle to visit county jails and transport clients to and from appointments and other locations as needed.

Required to have car insurance, a vehicle, and a valid driver's license

Bilingual, fluent Spanish/English oral and written skills are highly desirable.

Certifications or Licenses:

• Required: Preferred: Licensed or registered with the California Board of Behavioral Sciences (BBS) (e.g., ASW, AMFT, LCSW, LMFT)
• Preferred: Community Health Worker certification through California's HCAI Department.
• Driver's License

Skills/Abilities:

• Excellent interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in the community and within the organization.
• Strong clinical assessment and intervention skills
• Knowledge of trauma-informed care, reentry services, and behavioral health systems
• Ability to work in custodial and community environments
• Excellent communication, documentation, and organizational skills
• Ability to manage complex caseloads and competing priorities
• Strong collaboration skills within multidisciplinary teams
• Cultural competency working with diverse and underserved populations