Case Manager

Job Description Specifications

The Enhanced Care Management (ECM) Advocate is responsible for the and coordination, improving health outcomes, enhancing satisfaction, and reducing unnecessary healthcare utilization. ECM is a comprehensive, patient-centered approach to healthcare that aims to improve outcomes for high-need populations. This involves the coordination of medical, behavioral, and social services to address the full range of patient needs, focusing on those with complex and chronic conditions.

ECM programs are designed to optimize care delivery, reduce unnecessary hospitalizations, and improve the overall quality of life for . The intention of our services is to help people who have not been able to get the needed help in terms of Housing, Mental Health, Substance Abuse treatment, and linkages to community resources to help minimize recidivism. The role of the ECM Advocate is to help create a supportive network of services and resources for the client to prevent reincarceration and support long term permanent housing goals.

This position specifically serves students across Orange County, including both in-custody services within county jail settings andpost-release services in the community. The ECM Advocate must be comfortable working in secure correctional environments and in the field, ensuring continuity of care from incarceration through successful community reintegration. This role requires strict adherence to county jail access protocols, safety procedures, and visiting regulations, while also maintaining flexibility to meet students in community-based settings throughout the county.

• Conduct outreach to identify and engage eligible in ECM services, using multiple strategies and modalities for engagement.
• Interview and conduct assessments of students’ needs, including medical, behavioral, and social factors.
• Develop, implement, and monitor personalized care plans in collaboration with students, their families, healthcare providers, and community resources.
• Monitor and evaluate the effectiveness of care plans and making adjustments as needed to student goals.
• Serve as the primary point of contact for the student, relevant family members, and other supports.
• Operate as part of the student’s multi-disciplinary care team.
• Coordinate care across multiple providers and services, ensuring seamless integration of medical and social care.
• Act as a student advocate, ensuring the student’s needs and preferences are central to care decisions.
• Facilitate regular team meetings to review patient cases, address challenges, and share successes.
• Travel locally to deliver services to students in the community where they live, work, or frequent.
• Document services in the agency’s Electronic Health Record within 72 hours of each service and in compliance with agency policy, as well as contractual, state, and federal regulations.
• Coordinate and link the client to needed mental health, substance abuse, and housing resources.
• Maintained concise and comprehensive case records on all participants seeking services.
• Provide accurate daily and monthly documentation and case notes as per funding source guidelines.

• Attend workshops, meetings, and trainings as requested by supervisor.
• Provide in-person pre-release case management services within Orange County jail facilities, including conducting assessments, initiating care plans, and engaging students before release.
• Complete and maintain clearance for county jail access, including passing all required background checks and complying with facility-specific rules and regulations at all times.
• Adhere to all county jail visiting policies, procedures, and security protocols, demonstrating professionalism and compliance in a custodial setting.
• Deliver comprehensive pre-release planning, including development of individualized care plans, coordination of benefits, and linkage to housing, medical, and behavioral health services.
• Conduct post-release follow-up services in the community, ensuring continuity of care and successful transition from custody to community-based support systems.
• Schedule and coordinate medical and behavioral health appointments…