Enhanced Care Management Care Coordinator

About the role

Adobe Population Health (APH) is a women-owned health solutions company founded in 2018 with a mission to positively impact the lives we touch. Headquartered in Phoenix, AZ, APH fosters a culture rooted in inclusivity, human kindness, and high-quality care. Recognized by Inc. 5000 as one of America’s Fastest-Growing Private Companies and honored for a fifth consecutive year as a “Best Place to Work” by the Phoenix Business Journal, APH continues to expand its reach and impact.

Position Purpose

The Enhanced Care Management (ECM) Care Coordinator serves as the primary point of contact and Care Coordinator for assigned Medi-Cal members enrolled in California's Enhanced Care Management program. The ECM Care Coordinator provides comprehensive, person-centered care coordination services designed to improve health outcomes, address social determinants of health, reduce avoidable emergency department utilization and hospitalizations, and connect members to medical, behavioral health, community, and social support services.

Duties & Responsibilities

• Conduct outreach and engagement activities for members identified for ECM services.
• Establish trusting relationships with members and their support systems through culturally competent and trauma-informed approaches.
• Engage members primarily through in-person visits and utilize telephonic or virtual methods when appropriate.
• Serve as the member's primary point of contact throughout ECM enrollment.
• Promote member participation in care planning and healthcare decision-making.
• Complete comprehensive health and social needs assessments within required regulatory and contractual timelines.
• Identify medical, behavioral health, developmental, oral health, long-term services and supports (LTSS), housing, transportation, food insecurity, and other social needs.
• Develop individualized, person-centered Care Management Plans in collaboration with members, caregivers, and interdisciplinary care teams.
• Regularly review and update care plans based on member progress, changing needs, and clinical recommendations.
• Document strengths, goals, risks, barriers, interventions, and outcomes within the care plan.
• Coordinate services across physical health, behavioral health, specialty care, oral health, LTSS, community support, and social service systems.
• Facilitate communication among providers and multidisciplinary care teams to ensure continuity and integration of care.
• Schedule appointments, arrange transportation, provide appointment reminders, and assist members in overcoming barriers to care.
• Coordinate care among multiple care management entities to prevent duplication of services.
• Ensure member goals and preferences are communicated to all relevant care team members.
• Health Promotion and Member Self-Management
• Encourage members to actively participate in managing their health conditions.
• Identify and strengthen family, caregiver, and community support systems.
• Aid members in developing skills needed to access healthcare and community resources independently.
• Transitional Care Management
• Monitor hospital admissions, emergency department visits, skilled nursing facility stays, residential treatment admissions, and other care transitions.
• Conduct transition assessments and develop transition plans to support safe movement across care settings.
• Coordinate post-discharge follow-up appointments and services.
• Complete medication reconciliation activities following transitions of care.
• Implement interventions aimed at reducing avoidable hospital admissions and readmissions.
• Family and Caregiver Support
• Engage family members, caregivers, authorized representatives, guardians, and support people as appropriate and permitted.
• Ensure required consents and authorizations are obtained and maintained.
• Provide education to caregivers regarding care plans, treatment adherence, medication management, and available resources.
• Provide copies of care plans and educate members and caregivers on how to request updates or changes.
• Community Resource Coordination
• Identify social drivers of health impacting member outcomes, including housing instability, food insecurity, transportation barriers, employment, legal concerns, and financial hardship.
• Coordinate referrals to community-based organizations, social service agencies, and Community Supports providers.
• Ensure referrals are completed using a closed-loop process and verify services were received.
• Advocate for members to access necessary community and social support services.
• Documentation and Compliance
• Maintain accurate, timely, and complete member records in accordance with Medi-Cal, DHCS, health plan, and organizational requirements.
• Document all member contacts, assessments, interventions, referrals, and care coordination activities.
• Participate in audits, quality reviews, and compliance monitoring activities.
• Ensure all ECM services meet contractual, regulatory, and organizational standards.
• Protect member confidentiality and comply with HIPAA and applicable privacy regulations.
• Collaboration and Professional Development
• Participate in interdisciplinary care team meetings, case conferences, utilization reviews, and provider collaboration meetings.
• Attend required ECM, Medi-Cal, compliance, and organizational training programs.
• Collaborate with hospitals, primary care providers, behavioral health providers, specialists, LTSS providers, dental providers, and community organizations.
• Support organizational quality improvement initiatives and population health goals.

Skills & Qualifications

• Minimum of two (2) years of experience in case management, care coordination, population health, managed care, or related healthcare setting.
• Knowledge of California Medi-Cal managed care programs and Enhanced Care Management (ECM) model a plus.
• Experience working with high-risk and complex populations, including behavioral health and social determinants of health needs a plus.
• Excellent verbal, written, organizational, and interpersonal communication skills.
• Proficiency with electronic medical records, care management platforms, and Microsoft Office applications.
• Bilingual skills preferred based on regional needs.

Education, Licenses, & Certifications

• Bachelor’s degree in social work, human services, public health, psychology or related field required.
• Master’s degree preferred.
• Certified Case Manager (CCM) certification preferred.

Benefits & Total Rewards

• Paid Training and Onboarding
• Insurance – Medical, Dental, Vision, and Life
• 401k Plan – 3% match
• Employee Assistance Program
• Tuition Reimbursement
• Continued Education Support
• Mileage Reimbursement (if applicable)
• Referral Bonuses
• Paid Holidays (9 days)
• Paid Time Off (15 days)
• Paid Volunteer Hours