HATS - Health Advocacy Team Support
Enhanced Care Manager (ECM)
Job Summary
The Enhanced Care Manager (ECM) provides high-touch, person-centered care management for members with complex health and social needs. Under the California CalAIM initiative, the ECM is responsible for assessing member needs, developing comprehensive care plans, and coordinating across medical, behavioral, and social service systems. The goal of this role is to improve health outcomes, reduce unnecessary ER utilization, and address social determinants of health (SDOH) through direct advocacy and navigation.
Essential Duties & Responsibilities
Clinical Coordination & Case Management
Caseload Management: Maintain and manage a dedicated caseload of 35 to 40 members, ensuring regular contact and follow-up.
Comprehensive Assessments: Conduct psychosocial, physical, and environmental assessments to identify barriers to care and wellness.
Care Planning: Develop and implement individualized, culturally competent care plans that reflect member goals and clinical necessity.
Monitoring & Evaluation: Regularly monitor care plan effectiveness, updating strategies based on member progress, clinical changes, or compliance updates.
Discharge Planning: Coordinate hospital and skilled nursing facility (SNF) discharge planning to ensure a safe transition and continuity of care.
Advocacy & Resource Navigation
System Navigation: Act as a primary advocate to help members navigate the complexities of Medi-Cal, CalAIM, and other public benefits.
Wraparound Services: Identify, refer, and secure community-based resources, including housing, food security, and transportation.
Care Integration: Collaborate and communicate effectively with medical providers, mental health specialists, social workers, and housing agencies to close gaps in care.
Education: Provide health literacy coaching to members and their families regarding chronic disease management, behavioral health, and self-care.
Compliance & Administration
Documentation: Maintain meticulous, real-time documentation within the Electronic Health Record (EHR) in compliance with DHCS and county standards.
Regulatory Adherence: Strict adherence to HIPAA, CalAIM, and organizational privacy policies.
Professional Development: Participate in interdisciplinary team meetings and ongoing training as assigned by the Director of Operations.
Qualifications
Education & Experience
Education: Associate degree in a health-related or social services field required; Bachelor’s degree preferred.
Experience: Minimum of 2 years of direct experience in healthcare coordination, social work, or community-based social services.
Certifications & Licenses
Driver’s License: Valid California Driver’s License with a clean driving record and active auto insurance.
Life Support: Current Basic Life Support (BLS) certification from the American Heart Association (AHA).
Skills & Competencies
Technical: Proficiency in Google Drives
Interpersonal: Strong verbal and written communication skills; ability to build rapport with vulnerable populations.
Operational: Exceptional time management and the ability to work independently in a field-based/hybrid environment.
Physical Requirements & Working Conditions
Hybrid Nature: Requires a mix of remote administrative work and frequent travel for in-person home visits, community meetings, and team gatherings.
Travel: Must have access to a reliable vehicle and be willing to travel within the assigned territory. (Mileage reimbursement provided per IRS standards).
Physical Demands: Ability to sit/stand for extended periods, operate a computer, and occasionally lift up to 15 lbs.
Equal Opportunity Employer
HATS is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. All employment is decided on the basis of qualifications, merit, and business need.