Job Description
Job Description
POSITION SUMMARY
The ECM Lead Case Manager is responsible for providing direct services to clients referred to the CalAIM
Enhanced Case Management Program. This position plays a critical role in coordinating care among multiple
providers and addressing clients’ medical, behavioral, and social service needs. The ECM Lead Case
Manager creates individualized care plans that meet health plan requirements and address barriers to care,
including providing health education and coaching to promote long-term self-sufficiency.
The Lead Case Manager also serves as the primary point of contact for a client’s care team, which may
include primary care providers, behavioral health professionals, housing support services, SUD providers,
and natural supports. If a client is dually enrolled in CalAIM Community Supports, the Lead Case Manager
may also provide Housing Navigation or Housing Tenancy services as needed.
ESSENTIAL DUTIES AND RESPONSIBILITIES
The essential functions include, but are not limited to the following :
- Serve as the Enhanced Case Management (ECM) Lead Case Manager for assigned clients
- Maintain accurate and timely documentation and client records in compliance with program requirements
- Provide "hand-holding" services, including accompanying clients to initial appointments and helping
them navigate health systems
Deliver psychoeducation and teach clients the importance of addressing medical needs proactivelyEducate clients on how to attend and prepare for regular medical appointmentsProvide guidance on how untreated or unmanaged medical conditions may worsen over time
Act as a liaison among all of the client’s providers, ensuring coordinated and integrated service deliveryAdvocate for the client’s needs while promoting client voice and choice in all aspects of careSupport clients in accessing essential needs, such as food, transportation, housing, and public benefitsHelp clients develop daily living skills and long-term self-sufficiencyIdentify and reduce barriers to care, including transportation, health literacy, or psychosocial challengesParticipate in multidisciplinary team meetings and collaborate with community partnersMINIMUM QUALIFICATIONS (KNOWLEDGE, SKILLS, AND ABILITIES)
Minimum of 2 years of experience in case management, care coordination, or a related social services roleKnowledge of the Fresno Madera Continuum of Care and Housing ServicesStrong knowledge of medical terminology and chronic health conditionsLVN (Licensed Vocational Nurse) certification highly recommendedPrior experience working with individuals experiencing homelessness, serious mental illness, substanceuse disorder, or complex physical health conditions preferred
Familiarity with Medi-Cal, CalAIM, or managed care systems is a plusDemonstrated ability to provide compassionate, client-centered care and health educationExcellent interpersonal, organizational, and written communication skillsProficient in documentation and case noting in electronic systemsClean driving record