Lead Care Manager (ECM)

About the role

The Lead Care Manager under the supervision of the ECM Supervisor coordinates care and services for children, youth, and families enrolled in A Better Way's Enhanced Care Management (ECM) Program. The position involves utilizing a person-centered, family-driven, trauma-informed approach to engage families, identify strengths and barriers, coordinate services, and ensure successful linkage to healthcare, behavioral health, educational, and community resources.

Responsibilities

• Serve as the Lead Care Manager for assigned ECM members.
• Conduct outreach, engagement, and relationship-building activities with children, youth, and families.
• Complete comprehensive assessments and develop individualized care plans.
• Care Coordination & Service Planning
• Coordinate services across medical, behavioral health, educational, social service, and child welfare systems.
• Maintain closed-loop referrals to confirm families successfully access recommended services.
• Healthcare & PCP Coordination
• Establish and maintain relationships with Primary Care Providers (PCPs), specialists, hospitals, and healthcare organizations.
• Facilitate communication between healthcare providers and families.
• Coordinate appointments, follow-up care, medication support, and treatment recommendations.
• Support families in navigating healthcare systems and understanding medical care plans.
• Participate in multidisciplinary care meetings and case conferences.
• Referral Management & Resource Navigation
• Review and coordinate incoming ECM referrals.
• Aid in determining member eligibility and appropriate service linkage.
• Track referral outcomes and service engagement.
• Identify barriers to care and develop strategies to address access challenges.
• Maintain current knowledge of community resources throughout Alameda and San Francisco Counties.
• Develop, maintain, and regularly update ECM resource guides and community resource binders.
• Stakeholder Engagement
• Serve as a primary liaison between A Better Way and external partners.
• Build collaborative relationships with:
• Health Plans
• Primary Care Providers
• Behavioral Health Providers
• Child Welfare Agencies
• School Districts
• Regional Centers
• Community-Based Organizations
• Juvenile Justice Partners
• Represent A Better Way at community meetings, provider collaboratives, and stakeholder events.
• Promote awareness of ECM services and strengthen referral pathways.
• Family Support & Engagement
• Utilize motivational interviewing and family-centered engagement strategies.
• Support families in understanding and navigating complex service systems.
• Collaborate with Parent Partners and Family Partners to increase family engagement and service success.
• Absorb families in identifying natural supports and community connections.
• Promote self-advocacy and long-term family stability.
• Program Development & Quality Improvement
• Assist the ECM Supervisor in developing workflows, referral processes, and service coordination practices.
• Participate in program quality improvement activities.
• Support development of training materials and resource tools.
• Absorb tracking program outcomes and performance measures.
• Contribute to program growth and sustainability efforts.
• Documentation & Compliance
• Complete documentation within required timelines.
• Maintain accurate records within the electronic health record.
• Participate in audits, chart reviews, supervision, and training activities.
• Maintain compliance with Medi-Cal, CalAIM, HIPAA, and agency requirements.
• Other
• Participate in all mandatory trainings, including those required at onboarding and throughout the year, to maintain compliance and support ongoing professional development.
• Participate in regular competency and performance evaluations to support professional development, ensure role effectiveness, and maintain alignment with program and organizational standards.
• Follow regulatory guidelines, mandated reporting, and program/agency protocols in performing duties.
• Abide by all provisions of the A Better Way personnel manual.
• Perform any other duties as directed.

Qualifications

• Bachelor's degree in Social Work, Human Services, Public Health, Psychology, Child Development, Sociology, or a related field, or an equivalent combination of education and at least three (3) years of experience working with children, youth, and families in community-based settings.
• Demonstrated experience navigating healthcare, behavioral health, child welfare, educational, and social service systems.
• Strong understanding of systems of care and community resource networks.
• Experience coordinating services among multiple providers and stakeholders.
• Excellent communication, engagement, and relationship-building skills.
• Proficient in Microsoft Office Suite (Word, Excel, Outlook, and Teams) and electronic health record (EHR) systems.
• Ability to accurately enter, maintain, and retrieve data in electronic databases and care management platforms.
• Strong computer skills, including electronic documentation, virtual meeting platforms, internet research, and use of cloud-based applications.
• Valid California Driver's License, reliable transportation, and proof of current automobile insurance meeting California minimum coverage requirements. Ability to travel throughout assigned service areas.

Preferred

• Experience providing Enhanced Care Management (ECM), Targeted Case Management, Wraparound, or Care Coordination services.
• Knowledge of CalAIM and Medi-Cal managed care systems.
• Bilingual English/Spanish, or other threshold language.
• Experience working with foster youth, child welfare, behavioral health, or complex care populations.