SUMMARY:

The ECM (Enhanced Care Management) Care Coordinator plays a crucial role in Gracelight Community Health's commitment to delivering integrated, patient-centered care. This position is responsible for providing comprehensive care management services to eligible Medi-Cal members with complex medical, behavioral, and social needs. The ECM Care Coordinator will work directly with patients in their homes, communities, and Gracelight Community Health (Gracelight) clinic settings to navigate healthcare systems, connect with vital resources, and develop personalized care plans that address their unique circumstances and social determinants of health. Fluency in both English and Spanish is required for this role to effectively serve our diverse patient population.

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES:

1. Conduct outreach and engage with potential ECM-eligible patients, explaining the program benefits and facilitating enrollment.
2. Perform comprehensive, patient-centered assessments to identify medical, behavioral health, dental, developmental, and social needs, including barriers to care (e.g., housing instability, food insecurity, transportation).
3. Ensure care plans address identified social support and health-related social needs (e.g., housing transition/navigation, medically tailored meals, asthma remediation).
4. Oversee the effective implementation of care plans, monitoring progress, and making necessary adjustments in collaboration with the patient and care team.
5. Act as the primary point of contact and central hub for coordinating all aspects of the patient's care across various settings (e.g., primary care, specialty care, hospitals, community-based organizations).
6. Facilitate referrals and linkages to appropriate medical, behavioral health, social, educational, housing, food, transportation, and other necessary services.
7. Coordinate with hospital staff on discharge planning and ensure seamless transitions of care.
8. Provide health promotion, self-management education, and support to empower patients in managing their own health.
9. Maintain accurate, timely, and comprehensive documentation of all patient encounters, assessments, care plans, and interventions in the Electronic Health Record (EHR) and other designated tracking systems.
10. Ensure all documentation and program activities comply with Department of Health Services (DHS) requirements, health plan guidelines, and Gracelight's policies and procedures.
11. Participate in all health plan audits and seminars as applicable.
12. Regularly participate in interdisciplinary team meetings and case conferences to discuss patient progress and strategize care interventions.
13. Form and foster relationships with community agencies, housing providers, and other relevant organizations to expand resource networks for patients.
14. Advocate for patient rights, preferences, and access to necessary services.
15. Maintain current knowledge of ECM requirements, updates, and best practices.