ECM Lead Care Manager
Episcopal Community Services (ECS) · 972 Mission Street - San Francisco, CA 94103 ·
- Work mode
- Remote
- Seniority
- Lead
- Category
- Management
At Episcopal Community Services (ECS), employees work with participants who may be experiencing homelessness, behavioral health conditions, substance use challenges, and other difficult life circumstances. While this work is meaningful and mission-driven, it can at times be stressful, demanding, or unpredictable. Employees are expected to exercise sound judgment, remain aware of their surroundings, follow established safety, communication, and de-escalation procedures, participate in all required trainings, and promptly report incidents, threats, injuries, or unsafe conditions, in accordance with ECS policies and procedures.
This position is a fully onsite, client-facing role that requires in-person interaction and direct service delivery to participants at ECS program locations. Due to the essential nature of the duties and the need for consistent in-person engagement with clients, remote work or work-from-home arrangements are not available for this position.
POSITION SUMMARY
The Enhanced Care Management (ECM) Lead Care Manager is responsible for improving care coordination, improving health outcomes, enhancing satisfaction, and reducing unnecessary healthcare utilization. ECM is a comprehensive, patient-centered approach to healthcare that aims to improve outcomes for high-need populations. This involves the coordination of medical, behavioral, and social services to address the full range of patient needs, focusing on those with complex and chronic conditions. This program is designed to optimize care delivery, reduce unnecessary hospitalizations, and improve the overall quality of life for individuals served. The intention of our services is to help people who have not been able to access needed Housing supports, Mental Health/Substance Abuse treatment, and other community resources to help minimize recidivism. The role of the ECM Lead Care Manager is to facilitate multi-disciplinary team meetings and create a supportive network of services and resources for the client. The Lead Care Manager position requires experience in housing services, case management, and a passion for providing advocacy and in vivo support to individuals navigating complex social challenges.
PRIMARY DUTIES AND RESPONSIBILITIES
- Conduct outreach to identify and engage eligible in ECM services, using multiple strategies and modalities for engagement.
- Interview and conduct assessments of clients’ needs, including medical, behavioral, and social factors.
- Develop, implement, and monitor personalized care plans in collaboration with clients, their families, healthcare providers, and community resources.
- Monitor and evaluate the effectiveness of care plans and making adjustments as needed to client goals.
- Serve as the primary point of contact for the client, relevant family members, and other supports.
- Organize and facilitate the client’s multi-disciplinary care team.
- Coordinate care across multiple providers and services, ensuring seamless integration of medical and social care.
- Act as a client advocate, ensuring the client’s needs and preferences are central to care decisions.
- Facilitate regular team meetings to review patient cases, address challenges, and share successes.
- Travel locally to deliver services to clients in the community where they live, work, or frequent.
- Document services in the appropriate Electronic Health Record within 72 hours of each service and in compliance with agency policy, as well as contractual, state, and federal regulations.
- Coordinate and link the client to all needed resources and community services.
- Maintained concise and comprehensive case records on all participants seeking services.
- Provide accurate daily and monthly documentation and case notes as per funding source guidelines.
- Attend workshops, meetings, and trainings as requested by supervisor.
Performs other related duties as assigned.