Street Health ECM Care Coordinator

Job Description

Job Description

Street Health ECM Care Coordinator

Village Health Center

At Father Joe’s Villages, healthcare is more than providing medical services—it is about meeting people where they are, building trust, and helping individuals overcome barriers to health, housing, and long-term stability. Many of the individuals we serve face significant challenges navigating healthcare systems while experiencing homelessness, behavioral health conditions, substance use disorders, and other complex needs.

Our Street Health team bridges the gap between vulnerable community members and the care and resources they need. Through field-based outreach, engagement, and Enhanced Care Management (ECM), we help individuals access healthcare, behavioral health services, housing resources, and supportive services that promote improved health outcomes and greater stability. Every day, this team builds meaningful relationships, removes barriers to care, and helps individuals connect to services that support long-term wellbeing.

What Success Looks Like

This is a community-based role that combines outreach, engagement, care coordination, case management, and healthcare navigation. Successful Care Coordinators are approachable, organized, and committed to building trust with individuals who may be disconnected from traditional healthcare and social service systems. They are comfortable working independently in the field while collaborating closely with healthcare providers, case managers, managed care plans, and community partners.

Success in this role means building strong relationships with members, accurately coordinating care across multiple systems, connecting individuals to critical resources, and helping members achieve their health and housing goals. You'll help improve access to care, strengthen continuity of services, and support positive outcomes for individuals with complex medical, behavioral health, and social service needs.

The Role

• Conduct community outreach, field visits, home visits, and other engagement activities to identify and enroll individuals eligible for Enhanced Care Management (ECM) services.
• Build trust-based relationships with individuals experiencing homelessness and other barriers to health and housing stability using trauma-informed, Housing First, and harm-reduction approaches.
• Educate eligible individuals regarding ECM services and facilitate program enrollment.
• Maintain an assigned caseload of ECM members and provide ongoing care coordination and case management services.
• Complete assessments and participate in Interdisciplinary Care Team (ICT) meetings to develop, implement, and monitor individualized care plans.
• Coordinate medical care, behavioral health services, substance use treatment, housing resources, transportation, public benefits, and other supportive services.
• Connect members to the Coordinated Entry System (CES), healthcare providers, housing programs, public benefits, and other community resources.
• Monitor member progress and provide ongoing follow-up through field visits, clinic visits, phone contacts, and community-based engagement activities.
• Maintain timely and accurate documentation of assessments, care plans, outreach activities, referrals, and care coordination services in required systems.
• Collaborate with Street Health Outreach Workers, healthcare providers, managed care plans, and community partners to support integrated, person-centered care.

Desirable Candidate Profile

• High School Diploma or GED required; Associate degree in Social Work, Human Services, Psychology, Public Health, or a related field preferred.
• Minimum two (2) years of experience providing ECM, care coordination, case management, community health, street outreach, healthcare navigation, behavioral health, or related services supporting vulnerable populations.
• Experience working with individuals experiencing homelessness, housing instability, behavioral health conditions, substance use disorders, or other complex needs strongly preferred.
• Valid California Driver's License required.
• First Aid and CPR certification, or ability to obtain within the required timeframe
• Community Health Worker (CHW), Certified Peer Support Specialist, Mental Health First Aid (MHFA), Crisis Prevention Institute (CPI), or similar certifications preferred.
• Must be at least 21 years of age.

Key Competencies

• Knowledge of Enhanced Care Management (ECM), CalAIM, Medi-Cal managed care programs, and integrated care delivery models.
• Understanding of homelessness response systems, Coordinated Entry System (CES), housing navigation, and community-based resources.
• Knowledge of trauma-informed care, Housing First principles, harm reduction, motivational interviewing, and strengths-based engagement practices.
• Ability to build trusting relationships with individuals experiencing complex medical, behavioral health, housing, and social service needs.
• Strong care coordination, resource navigation, advocacy, and problem-solving skills.
• Ability to manage an active caseload while balancing outreach, documentation, referrals, and changing member needs.
• Strong communication, organizational, and follow-through skills.
• Ability to work effectively both independently and as part of a multidisciplinary team.
• Commitment to serving individuals with compassion, respect, empathy, empowerment, and dignity.

Work Schedule

This is a full-time position that combines community-based outreach, care coordination, field-based case management, healthcare navigation, and member engagement activities throughout the community. Work is performed in a variety of settings, including streets, encampments, shelters, healthcare facilities, community locations, and office environments. While the typical schedule is Monday through Friday, occasional schedule flexibility may be required to support member needs, outreach activities, community partnerships, and operational priorities.

Compensation & Benefits

The anticipated starting pay range for this role is $24.00 to $27.61 per hour, paid out bi-weekly. Final placement and starting pay rate will be determined based on the candidate's experience, qualifications, certification status, and internal equity considerations.

Father Joe’s Villages offers a comprehensive benefits package, including medical, dental, and vision coverage, retirement plan options, paid time off, and professional development opportunities. Employees also have access to wellness programs and employee assistance resources to support work-life balance and overall well-being.

Why Join Father Joe’s Villages

Join an organization deeply rooted in Compassion, Respect, Empathy, Empowerment, and Dignity. Make a meaningful impact by helping individuals experiencing homelessness access healthcare, supportive services, and pathways to greater stability. Work alongside a collaborative, mission-driven team committed to trauma-informed care, Housing First principles, and whole-person wellness. Grow your skills in care coordination, healthcare navigation, outreach, and community-based services while helping some of our community's most vulnerable individuals improve their health and quality of life.

Conditions of Employment

Employment is contingent upon successful completion of applicable pre- and post-employment requirements, which may include background checks, health screenings, license or certification verification, driving record review, and other requirements relevant to the role. These checks are conducted following a conditional offer of employment.

Equal Employment Opportunity

Father Joe’s Villages is an equal opportunity employer dedicated to building a diverse, inclusive workforce. All qualified applicants will receive consideration without regard to race, color, religion, sex, sexual orientation, gender identity, age, national origin, disability, veteran status, or any other characteristic protected by law.