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Summary:

The Lead Care Manager for the Enhanced Care Management (ECM) program plays a critical role in improving health outcomes for Medi-Cal members with complex medical and social needs. This position is responsible for providing comprehensive, member-centered care coordination and case management services that address the clinical, behavioral, and social drivers of health. The Lead Care Manager collaborates closely with internal providers, external partners, and community-based organizations to ensure continuity of care and effective resource utilization. 

Essential Duties and Responsibilities:

Primary Functions:

1. Coordinate with clinical staff to conduct comprehensive health assessments, including medical, behavioral, functional, and social determinants of health (SDOH), for each assigned ECM member.
2. Coordinate with clinical staff to Develop, implement, and update individualized care plans that reflect member goals, needs, and measurable outcomes, ensuring alignment with HRSA core clinical performance measures (e.g., diabetes, hypertension, depression screening).
3. Coordinate care across primary care, behavioral health, dental, substance use, housing, and specialty systems to address whole-person health needs in accordance with HRSA’s integrated services model
4. Track and follow up on referrals to specialty care, housing services, substance use treatment, behavioral health, and other wraparound supports.
5. Coordinate multidisciplinary team meetings and case conferences with providers, behavioral health clinicians, community health workers, and social services
6. Document all case management interactions and interventions in the EHR and ECM tracking system within required timeframes.
7. Collaborate with the Managed Care Plan’s ECM team and CalAIM stakeholders as needed to ensure program compliance and alignment.
8. Identify and resolve barriers to care, including access to transportation, medication adherence, or cultural/language needs.
9. Participate in population health initiatives, quality improvement activities, and care team huddles to enhance patient outcomes and operational effectiveness
10. Monitor high-risk member panels using risk stratification tools and provide appropriate intensity of services based on member acuity.
11. Provide patient navigation support, health system education, and linkage to resources.
12. Maintain current knowledge of ECM program requirements, Medi-Cal managed care benefits, and community resources.
13. Collaborate with CHW’s and Navigators as part of the care team.
14. Maintain complete, timely, and compliant documentation for all services provided, supporting HRSA grant deliverables, compliance monitoring, and managed care ECM reporting
15. Respond to crises and escalating needs with urgency, de-escalation skills, and coordination with emergency or behavioral health resources.
16. Participate in the annual Uniform Data System (UDS) data collection process, contributing relevant case management and clinical coordination data.
17. Maintain confidentiality and comply with all HIPAA regulations and ECM program data-sharing requirements.
18. Active involvement in the community to educate about risk factors for chronic disease, increase community-based screening methodologies, and recruit newly diagnosed individuals to SDAIHC for treatment and management. 
19. Assist with program evaluation, including performance measurement, member satisfaction surveys, and continuous quality improvement related to HRSA funding expectations and ECM contractual obligations
20. Adhere to organizational and departmental policies and procedures.
21. Perform the clinical and administrative duties necessary to meet the goals and objectives of the grant. 
22. Maintain 50 patient case load after 6 months
23. Other duties as assigned.

Minimum Qualifications:

1. Education and/or Experience: Bachelor’s degree in social work, public health, psychology, or related field or equivalent experience in care coordination/ case management.
2. Ability to view the patient as a whole person within the context of their family and community.
3. Excellent interpersonal and communication skills.
4. Computer and analytic skills to run reports and review data.
5. Minimum of 2 years of experience, preferably in community health, case management, or care coordination Must be a team player and be willing to put the needs of the patients first.

Minimum Qualifications: continue

1. Understand requirements for Patient Centered Medical Home.
2. Experience working with vulnerable populations (e.g., individuals with SMI/SUD, homelessness, complex medical needs)
3. Strong knowledge of Medi-Cal benefits, community resources, and health care delivery systems.
4. Valid driver’s license and reliable transportation for community-based visits

Preferred:

1. FQHC background.
2. Familiarity with community health clinics and/or Indian Health Clinics.
3. ECW EHR.
4. Prefer a master’s degree from an accredited university or professional school for a Nursing, and at least 2 years of experience; or a BA and 4 years’ experience

Special Conditions of Employment:

1. CPR/ BLS certification: Maintain a current Basic Life Support (BLS) certification issued by the American Heart Association (AHA), the American Red Cross, or an equivalent organization. Certification must include an in-person, hands-on skills assessment. Online-only certifications are not accepted.
2. Annual background checks: Consent to annual background checks as a condition of continued employment, to ensure compliance with organizational standards and eligibility requirements.
3. For-Cause Drug Screening: Comply with drug screening requirements when initiated by the organization for cause, to support a safe, compliant, and drug-free workplace.
4. Ongoing Compliance Requirements: Maintain up-to-date compliance with all required annual renewals, including professional licenses, certifications, physical examinations, TB testing, and mandatory regulatory trainings as assigned by the San Diego American Indian Health Center (SDAIHC

Knowledge, Skills, and Abilities:

Excellent verbal and written communication skills.

1. Excellent interpersonal, negotiation, and conflict resolution skills.
2. Excellent organizational skills, record-keeping skills and attention to detail. 
3. Excellent time management skills with a proven ability to meet deadlines.
4. Strong analytical and problem-solving skills. 
5. Ability to prioritize tasks and to delegate them when appropriate.
6. Ability to act with integrity, professionalism, and confidentiality. Proficient with Microsoft Office Suite or related software. Proficiency with or the ability to quickly learn the organizations EMR and other billing software systems.

Physical and Mental Requirements:

1. Able to lift/move up to 20 pounds, move from place to place.
2. Able to stand, bend and reach for prolonged periods.  
3. Ability to do math, organize and prioritize workload, work effectively and efficiently under stress.
4. Ability to supervise, multitask, understand, and follow instructions.
5. Ability to proficiently read, write, speak, and understand English.

Customer Service:

1. Actively supports, promotes, and works to fulfill the Mission, Vision, and core values of SDAIHC.
2. Provides excellent internal and external customer service.  
3. Demonstrates SDAIHC’s Standards of Customer Service Behavior: Compassion, Attitude, Communication, Appearance, Sense of Ownership, and Teamwork.
4. Participates in on-going customer service training.
5. In every action, seeks to promote SDAIHC as a top service organization.

Quality Management:

1. Contribute to the success of the organization by participating in quality improvement activities.
2. Complies with all SDAIHC policies and procedures and proactively participates in the implementation of new initiatives.
3. Participate and ensures continuous quality improvement process as directed by clinic leadership.  

Safety:

1. Ensures regulatory compliance and adherence with policies and procedures related to safe work practices.
2. Participate in infection prevention through appropriate use of infection control measures during patient treatment and patient interactions.
3. Ensure compliance with regulatory requirements for maintaining physical spaces, equipment, and supplies.  
4. Uses all appropriate equipment and/or tools to ensure workplace safety. 
5. Immediately reports unsafe working conditions. 

Privacy/Compliance:

1. Maintains privacy and security of all patients, employee, and volunteer information and access to such information. Such information is accessed on a need-to-know basis for business purposes only. 
2. Complies with all regulations regarding corporate integrity and security obligations. Reports on unethical, fraudulent, or unlawful behavior or activity.
3. Upholds strict ethical standards.

Flexibility: Available for all shifts and, when required, able to work evenings and weekends

Disclaimer

Nothing in this job description restricts management's right to assign or reassign duties and responsibilities to this job at any time. This description reflects management’s assignment of essential functions; it does not proscribe or restrict the tasks that may be assigned. This job description is subject to change at any time.

Acknowledgement

San Diego American Indian Health Center is an Equal Opportunity Employer. We encourage applications from all individuals regardless of race, religion, color, sex, pregnancy, national origin, sexual orientation, gender identity, gender expression, ancestry, age, marital status, physical or mental disability or any other protected class, political affiliation, or belief.