Enhanced Care Management - Outreach Specialist

Description:

Position Overview:

Under the guidance of the ECM Clinical Supervisor and ECM Director, the Outreach Specialist is responsible for engaging with potential participants in the community and connecting them to the Enhanced Care Management (ECM) program. The primary goal of this role is to identify, reach, and bring new clients into the program so they can become active ECM members, while ensuring each client meets the required Population of Focus (POF) criteria.

The Outreach Specialist works primarily in the field, meeting clients where they are, building trust, and encouraging enrollment into ECM services. They collaborate as part of the ECM Care Team, engaging with participants, families, healthcare providers, and community partners to support a smooth transition into the program.

Their focus is on targeted outreach and relationship-building, ensuring that new clients both meet eligibility requirements and understand the benefits of ECM. By guiding clients into services, Outreach Specialists help expand access to high-quality, coordinated care for individuals and families with complex medical, behavioral, and social needs.

Requirements:

Community Outreach & Engagement

• Conduct proactive outreach in shelters, clinics, hospitals, encampments, and other community settings to identify potential ECM participants.
• Educate individuals, families, and community partners about the Enhanced Care Management (ECM) program.
• Build trust with potential clients and their families to promote engagement in ECM services.
• Ensure that all potential clients meet the Population of Focus (POF) criteria prior to enrollment.
  

Client Enrollment & Transition to ECM

• Support individuals through the intake and enrollment process, including explaining program benefits, answering questions, and assisting with necessary forms.
• Facilitate smooth handoffs of newly enrolled clients to ECM Care Managers for ongoing case management.
• Document outreach efforts, eligibility verification, and enrollment activities accurately in the electronic health record (EHR) system.
• Track referrals and follow up to ensure clients successfully transition into ECM services.
  

Collaboration & Coordination

• Partner with the ECM Clinical Supervisor, ECM Director, Care Managers, healthcare providers, and community-based organizations to coordinate outreach efforts.
• Work with internal BVHPF program staff to identify and refer clients who may benefit from ECM services.
• Maintain professional, trauma-informed, and culturally responsive communication with clients, families, and community stakeholders.
  

Barrier Reduction & Resource Navigation

• Identify barriers preventing clients from accessing healthcare or social services, and connect them with appropriate resources.
• Provide navigation support such as assisting with transportation arrangements, appointment reminders, or referrals to housing, food, or other supportive services.
• Help clients and families understand their health plan benefits under their Managed Care Plan (MCP).
  

Crisis Response & Supportive Engagement

• Use trauma-informed, evidence-based approaches such as Motivational Interviewing (MI) to de-escalate and provide supportive engagement during outreach interactions.
• Ensure immediate needs are addressed and connect clients to appropriate crisis or urgent care resources.
  

Program Development & Continuous Improvement

• Represent the voice of the community by sharing feedback and insights that inform ECM program improvements.
• Participate in Continuous Quality Improvement (CQI) initiatives to help strengthen outreach strategies and enrollment outcomes.
• Attend ECM team meetings, trainings, and case reviews as appropriate.
• Ensure all documentation is accurate, complete, and compliant with BVHPF and MCP requirements.
• Perform other duties as assigned by the ECM Clinical Supervisor or ECM Director.

Qualifications:

Experience: Minimum 3-5 years in outreach and engagement with combination with, high-need care coordination and management, including those with mental health conditions, homelessness, and substance use disorders, with at least 1-2 years lived experience, including experience working with LGBTQI+, young people and their families, caregivers, child welfare, foster system, older adults and individuals with chronic illness communities.

Leadership Skills: Strong communication and interpersonal skills, with problem-solving skills. Ability to work independently and as part of a team.

Knowledge: In-depth understanding of high-need care coordination, chronic disease management, behavioral health, social determinants of health (SDOH), community resources and healthcare services.

Technical Skills: Proficiency in case management software such as: electronic health records (EHR), Avatar, Epic and data reporting tools, including knowledge of Microsoft Office, Internet browsers, etc.

Physical & Additional Requirements:

Regular and reliable job attendance.

Effective verbal and written communication skills.

Exhibit respect and understanding of others to maintain professional relationships.

Independent judgement in evaluation options to make sound decisions.

Ability to work effectively in an open office environment surrounded by moderate noise and distractions.

Frequently required to sit; occasionally walk and stand; travel from the building to other sites.

Specific vision abilities required by this job include close vision, distance vision, depth perception, and the ability to adjust focus.

The employee must be able to meet case notes deadlines with time constraints.

Able to meet required state, federal, local and BVHP standards.

Live Scan fingerprinting and TB clearance as well as any other medical vaccinations may be required.

At least two COVID-19 vaccinations (preferred).

As part of our commitment to maintaining a secure environment, all candidates selected for this position will be subject to a comprehensive background check clearance. This clearance is a standard part of our employment process and is conducted in accordance with applicable laws and regulations.

Provide proof of California Driver’s Licenses, proof of insurance and current registration with a clean driving record.

Additional Requirements:

Bilingual (English/Spanish or English/Cantonese/Mandarin) skills preferred.

Completion of a minimum of 6 (six) hours of continuing education training annually.

Top-Tier engagement in a variety of settings: in-person, phone, In-home, facilities.

May require occasional evening and weekend to managed care

Excellent verbal and written communication skills in writing and proofreading.

Exhibit respect and understanding of others to maintain professional relationships.

Ability to work as part of a team and independent judgement to make sound decisions.