RH Community Builders
CalAIM ECM Lead Case Manager
Position Summary
The ECM Lead Case Manager is responsible for providing direct services to clients referred to the CalAIM Enhanced Case Management Program. This position plays a critical role in coordinating care among multiple providers and addressing clients’ medical, behavioral, and social service needs. The ECM Lead Case Manager creates individualized care plans that meet health plan requirements and address barriers to care, including providing health education and coaching to promote long-term self-sufficiency.
The Lead Case Manager also serves as the primary point of contact for a client’s care team, which may include primary care providers, behavioral health professionals, housing support services, SUD providers, and natural supports. If a client is dually enrolled in CalAIM Community Supports, the Lead Case Manager may also provide Housing Navigation or Housing Tenancy services as needed.
Essential Duties and Responsibilities
The essential functions include, but are not limited to the following:
Serve as the Enhanced Case Management (ECM) Lead Case Manager for assigned clients
Maintain accurate and timely documentation and client records in compliance with program requirements
Provide "hand-holding" services, including accompanying clients to initial appointments and helping them navigate health systems
Deliver psychoeducation and teach clients the importance of addressing medical needs proactively
Educate clients on how to attend and prepare for regular medical appointmentsProvide guidance on how untreated or unmanaged medical conditions may worsen over time
Act as a liaison among all of the client’s providers, ensuring coordinated and integrated service delivery
Advocate for the client’s needs while promoting client voice and choice in all aspects of care
Support clients in accessing essential needs, such as food, transportation, housing, and public benefits
Help clients develop daily living skills and long-term self-sufficiency
Identify and reduce barriers to care, including transportation, health literacy, or psychosocial challenges
Participate in multidisciplinary team meetings and collaborate with community partners
Minimum Qualifications (Knowledge, Skills, and Abilities)
Minimum of 2 years of experience in case management, care coordination, or a related social services role
Knowledge of the Fresno Madera Continuum of Care and Housing Services
Strong knowledge of medical terminology and chronic health conditions
LVN (Licensed Vocational Nurse) certification highly recommended
Prior experience working with individuals experiencing homelessness, serious mental illness, substance use disorder, or complex physical health conditions preferred
Familiarity with Medi-Cal, CalAIM, or managed care systems is a plus
Demonstrated ability to provide compassionate, client-centered care and health education
Excellent interpersonal, organizational, and written communication skills
Proficient in documentation and case noting in electronic systems
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