ECM Case Manager - (SUD Population Focus)

Job Summary

The ECM Case Manager provides whole-person, member-centered care management services to Medi-Cal members with complex health and social needs, with a primary focus on individuals impacted by substance use disorders (SUD).

Duties And Responsibilities

• Member Engagement and Outreach
• Conduct field-based, community-based, and telephonic outreach to engage ECM-eligible members.
• Establish trusting relationships with members through a trauma-informed and culturally responsive approach.
• Meet members where they are, including homes, shelters, treatment facilities, hospitals, community settings, and other approved locations.
• Maintain ongoing contact with members according to ECM program requirements.
• Assessment and Care Planning
• Complete comprehensive assessments of members' physical health, behavioral health, substance use, housing, social support, and resource needs.
• Develop individualized care plans that reflect member goals, strengths, and priorities.
• Monitor progress toward care plan goals and update plans as needed.
• Identify barriers to healthcare access and engagement.
• Care Coordination
• Coordinate services across medical, behavioral health, social service, and community-based systems.
• Facilitate communication among providers, health plans, community organizations, and support networks.
• Aid members in scheduling and attending appointments.
• Support transitions of care following emergency department visits, hospital admissions, residential treatment episodes, incarceration, or other significant life events.
• Ensure members receive appropriate follow-up services and supports.
• SUD-Focused Care Management
• Support individuals with substance use disorders through engagement, education, advocacy, and resource navigation.
• Coordinate referrals and warm handoffs to substance use treatment and recovery support programs.
• Aid members in accessing:
• Medication-Assisted Treatment (MAT)
• Outpatient treatment programs
• Residential treatment services
• Recovery support services
• Behavioral health services
• Peer support programs
• Promote harm reduction and recovery-oriented principles.
• Encourage member participation in services while respecting individual choice and readiness for change.
• Community Supports Coordination
• Assist members in accessing CalAIM Community Supports and other community resources.
• Coordinate housing-related services including housing navigation, tenancy support, and housing stabilization resources when appropriate.
• Support access to transportation, food resources, public benefits, and community-based services.
• Advocate for members within healthcare, housing, and social service systems.
• Documentation and Compliance
• Maintain accurate, timely, and complete documentation in electronic health records and care management systems.
• Document assessments, care plans, member contacts, referrals, and outcomes according to organizational and regulatory requirements.
• Participate in case conferences, interdisciplinary care team meetings, and quality improvement activities.
• Adhere to CalAIM ECM, Medi-Cal Managed Care, HIPAA, and organizational requirements.