About The Role

DescriptionJOB 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). Through outreach, engagement, assessment, care planning, coordination, and follow-up, the ECM Care Manager supports members in accessing medical, behavioral health, housing, and community-based services that improve health outcomes and overall well-being.

The ECM Case Manager does not provide substance use counseling, psychotherapy, or clinical treatment services. Instead, the role focuses on care coordination, service linkage, advocacy, and member engagement to help individuals navigate complex systems of care.

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.
Assist 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.

Assist 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.

QualificationsEducation

Bachelor's degree in Social Work, Human Services, Psychology, Public Health, Nursing, Health Administration, or related field; OR
Equivalent education and experience consistent with organizational and ECM program requirements.

Experience

At least one (1) year of experience in care management, case management, behavioral health, homeless services, social services, community health, or a related field.
Experience working with individuals with substance use disorders and knowledge of recovery-oriented and harm-reduction approaches required.
SUD counseling certification is not required, as this position functions within a care management and care coordination capacity rather than a treatment or counseling role
Experience serving Medi-Cal or other vulnerable populations preferred.

Knowledge, Skills, and Abilities

Knowledge of Enhanced Care Management and Community Supports preferred.
Understanding of substance use disorders, recovery principles, and harm reduction practices.
Knowledge of community resources, healthcare systems, and social service programs.
Strong motivational interviewing and engagement skills.
Ability to work independently in field-based environments.
Strong organizational, communication, and documentation skills.
Ability to maintain professional boundaries and confidentiality.
Commitment to person-centered, trauma-informed, and culturally responsive care.

Preferred Qualifications

Experience working in ECM, Health Homes, Whole Person Care, behavioral health, homeless services, or community health programs.
Community Health Worker (CHW), Certified Case Manager (CCM), or related certification preferred.
Experience working with Medi-Cal managed care populations.
Bilingual skills preferred.

SPECIAL REQUIREMENTS

Must have a reliable automobile for use on the job (mileage to be reimbursed).
Valid California Driver License and automobile insurance coverage.
Subject to a criminal background check prior to employment
TB clearance, to be renewed every year. Vaccines and boosters as needed.
Compliance with all mandated vaccinations and all boosters is a term and condition of employment.

Equal Opportunity Statement

Via Care Community Health Center provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, marital status, amnesty, or status as a covered veteran in accordance with applicable federal, state and local laws. Via Care Community Health Center complies with applicable state and local laws governing non-discrimination in employment in every location in which the organization has facilities. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

In compliance with California Labor Code § 432.3, as amended effective January 1, 2026, this job posting includes the pay scale for the position. The pay scale represents a good‑faith estimate of the salary or hourly wage range the employer reasonably expects to pay for the position upon hire. Actual compensation within the posted range will depend on experience, skills, and internal equity.