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Job Description:

Lead Care Manager (Enhanced Care Management Program)

Status: Non-Exempt, Full-Time
Department: ECM
Reports To: ECM Site Manager or designee
Work Schedule: 8-hour shift, Monday through Friday. However, flexibility is required due to the nature of business. The schedule may be changed as needed.


The Enhanced Care Management (ECM) Lead Care Manager is responsible for coordinating care and services among the physical, behavioral, dental, developmental, and social service delivery systems ensuring individuals receive the right care at the right time and become, or remain, able to live successfully in their communities. The ECM Lead Care Manager supports program growth by making initial contact in engaging with potential patients, providing information about Enhanced Care Management services, and enrolling patients. The ECM Lead Care Manager will determine eligibility, complete enrollment assessments and work with our program partners to oversee the eligible patient population for the ECM Program.


⦁ Accompany MCP Member to office visits, as needed and according to MCP guidelines.
⦁ Connect MCP Member to other social services and supports needed.
⦁ Educate MCP Members about MCP Member benefits, including crisis services, transportation services, etc.
⦁ Distribute health promotion materials.
⦁ Advocate on behalf of MCP Members with health care professionals
⦁ Use motivational interviewing, trauma-informed care, and harm-reduction practices.
⦁ Work with hospital staff on discharge plan
⦁ Contact MCP Member to schedule in-person visit with the contract provider.
⦁ Responsible for accurate and timely documentation which includes but is not limited to program enrollment, assessment, updated activity/progress notes, resource access applications, releases of information, and any other forms necessary to document services.
⦁ Provides ongoing monitoring of the Targeted Engagement List (TEL).
⦁ Conducts regular telephonic outreach and follow-up with ECM Patients.
⦁ Complete comprehensive Intake assessments.
⦁ Assist members in accessing additional benefits and related documentation such as, Social Security Insurance (SSI), Cal Fresh, cash aid, and housing.
⦁ Assigns Patients to the appropriate ECM Care Team members based on risk category and available clinical data for ECM engagement activities.
⦁ Carries a caseload of 50 patients and assists with any health or social needs they may have until the Patient can maintain their overall needs on their own.

⦁ Supports other ECM Care Team members with delegated tasks.
⦁ Responsible for assisting patients with care coordination needs, including, but not limited to, referral support, community resource connection, health care navigation, and tracking all referrals in the designated logs and/or electronically.
⦁ Responsible for engaging with patients, both in-person and on the phone, in a manner that utilizes evidence-based approaches (such as Motivational Interviewing) that promote collaboration between the Patient and their medical/behavioral health team, as well as increase the Patient’s sense of control over their whole health.
⦁ Assess for substance use recovery support services and treatment options.
⦁ Forms and fosters relationships with housing agencies and permanent housing providers, including supportive housing providers.
⦁ Assists with coordinating medical and behavioral health access issues with PCP offices, Specialists, and Ancillary Services.
⦁ Ensures the privacy and security of Protected Health Information (PHI) as outlined in the policies and procedures relating to HIPPA compliance.
⦁ Ensures documentation is accurate and in compliance with regulatory requirements and accreditation standards.
⦁ Meet or discuss with patients any and all aspects of the referral process as needed or requested by the treating provider.
⦁ Complete face-to-face interviews with the Patient to obtain detailed information related to social service needs.
⦁ Schedule appointments with community-based resources with patients.
⦁ Collaborates on Patient care issues with other ECM Care Team members, participates in systematic case reviews, and consults with other ECM Care Team members.
⦁ Uses relationship-based and motivational interviewing strategies to engage Patients in Care.
⦁ Assists with arranging transportation and completion of durable medical equipment requests.
⦁ Coordinates with ECM Patients in the most easily accessible setting
⦁ Positively impact patient experience by demonstrating values of Transforming Care including, but not limited to, courteous and helpful behavior and a commitment to accuracy.
⦁ Other duties as assigned, including, but not limited to verification of insurance eligibilities, submission of treatment authorizations, and other duties as assigned.


⦁ Contribute to the success of the organization by participating in quality improvement activities.
⦁ Document as necessary in required Electronic Medical Record portals and Managed Care Plan portals for all care coordination and other services or teaching provided in a timely manner.
⦁ Prioritizes activities according to intensity, need, and required follow-up.


⦁ Effective written and verbal communication skills
⦁ Organization/Time management skills
⦁ Ability to think critically, solve problems creatively, and effectively assist clients in demanding situations.
⦁ A positive attitude, desire to learn and grow and aspirations to lead.
⦁ A focus on the growth and well-being of people and the communities to which they belong.
⦁ Excellent verbal, written and interpersonal communication skills.
⦁ High level of proficiency in web-based systems, real-time communication systems (i.e., chat), Microsoft Office, and other Client Record Management systems.
⦁ Familiarity and experience in the areas of community outreach, behavioral health, and working with high-risk populations.
⦁ Equivalent combination of education, training, and work experience to demonstrate the ability to perform the above tasks.
⦁ CA driver’s license and proof of car insurance are required.


⦁ Work and communicate effectively with staff, families, community agencies, and professionals.
⦁ Perform crisis intervention strategies.
⦁ Communicate effectively orally and in writing.
⦁ Work effectively under stress and conflict.
⦁ Exercise appropriate judgment and decision making.
⦁ Be flexible and adaptable in any given situation.
⦁ Work as a member of a team.
⦁ Be well organized, flexible, and self-disciplined.
⦁ Knowledge of medical terminology.
⦁ Computer skills, including familiarity with spreadsheets, databases, scanning, printing, and faxing.
⦁ Effective communication and organizational skills.
⦁ The ability to interact effectively with clinic personnel, patients, and community-based organizations.
⦁ Highly skilled interpersonally, with excellent teamwork and relationship skills.
⦁ Knowledgeable about evidenced based communication, such as Motivational Interviewing or similar empathy-based communication strategies (emotional intelligence).
⦁ Able to sufficiently engage members and providers on the phone and in person.
⦁ Understanding of and sensitivity to the multicultural community.
⦁ Understanding of and sensitivity to mental health conditions and addictive disorders.
⦁ Awareness of unmitigated bias and judgment impact on health; commitment to addressing both.
⦁ Strong organizational skills, proficiency in Windows applications, telephone courtesy, high degree of patience, and experience in data entry.
⦁ Understanding of and a commitment to high-performing team practices.


⦁ Prolonged periods of sitting at a desk and working on a computer.
⦁ Must be able to move intermittently throughout the workday.
⦁ Must be able to speak and write the English language in an understandable manner.
⦁ Must be able to cope with the mental and emotional stress of the position.
⦁ Must function independently, have personal integrity, have flexibility, and have the ability to work effectively with other personnel.
⦁ Must be able to push, pull, move, and/or lift a minimum of 25 pounds to a minimum


⦁ Follow all safety procedures and immediately report any injuries and/or unsafe conditions.
⦁ Maintain current knowledge of policies and procedures related to safe work practices.
⦁ Follow all safety procedures and report unsafe conditions.
⦁ Use appropriate body mechanics to ensure an injury-free environment.
⦁ Be familiar with the location of the nearest fire extinguisher and emergency exits.
⦁ Maintain the privacy of all patients, employees, and volunteer information and access such information only on a need-to-know basis for business purposes.
⦁ Comply with all regulations regarding corporate integrity and security obligations.
⦁ Report all behavior and/or activity that are unethical, fraudulent, or unlawful.
⦁ Staff will travel within the San Diego region as needed. Mileage reimbursement for the use of your vehicle is at a standard rate. Possession of valid driver’s license and proof of State required auto liability insurance.


High School Diploma or GED. Medical Assistant, CNA, EMT, other healthcare experience.
1-3 years of experience in Community Outreach, Customer Service, Sales, or experience in a healthcare setting, involvement in volunteering initiatives. Familiar with Motivational Interviewing. Equivalent combination of education and experience that provides the skills, knowledge, and ability to perform the essential job duties, and which meets any required state or federal certification requirements.
Language: Fluent in English (written and verbal). Bilingual Spanish highly preferred.


⦁ Dental insurance
⦁ Health insurance
⦁ Paid time off
⦁ Vision insurance


Moderate noise level; fast pace, high energy. Prolonged periods of sitting. Extensive use of telephone.


Maintains patient, employee and Foundation confidentiality at all times, discussing patient or employee business only with appropriate parties who have a bona fide need to know; and communicating only the minimum amount of information necessary with respect to protected health information (PHI) as defined by the Health Insurance Portability and Accounting Act of 1996 (HIPAA).
Please be aware AMERICAN TRUECARE, INC. requires all employees to be vaccinated for COVID-19. This position will require the successful candidate to show proof of a vaccination. AMERICAN TRUECARE, INC is an equal opportunity employer, and will provide reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law.

I acknowledge that I have read and understand the above job description in its entirety and am capable of performing all the stated requirements.


I have received a copy of the job description for my position:
Position: LEAD CARE MANAGER, (non-clinical) Enhanced Care Management.

I have reviewed this job description and I understand all my job duties and responsibilities. I am able to perform the essential functions as outlined. I understand that my job may change on a temporary or regular basis according to the needs of my department without it being specifically included in the job description. If I have any questions about job duties not specified on this description that I am asked to perform, I should discuss them with my immediate supervisor or a member of the Human Resources staff.

I further understand that future performance evaluations and merit increases to my pay are based on my ability to perform the duties and responsibilities outlined in this job description to the satisfaction of my immediate supervisor.

I have discussed any questions I may have had about this job description prior to signing this form.

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