Enhanced Care Management Coordinator

Location: California

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* Title:

** Enhanced Care Management Coordinator
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* Summary:

** The Enhanced Care Management (ECM) Coordinator supports the delivery of enhanced care management services for high-need Medi-Cal members served by TMWIHC. Reporting to the Tribal Registered Nurse, this position coordinates comprehensive care plans, facilitates interdisciplinary care team collaboration, and connects members with community resources to address social determinants of health and improve health outcomes.
* Serve as the primary care coordinator for high-need Medi-Cal members enrolled in the Enhanced Care Management program.
* Conduct comprehensive needs assessments and develop individualized care plans in collaboration with the patient and care team.
* Coordinate services across medical, behavioral health, social services, and community support domains.
* Connect members with community resources and social services to address housing, food security, transportation, and other social determinants of health.
* Maintain regular contact with assigned members through in-person visits, phone, and telehealth.
* Document all care management activities accurately and timely in the electronic health record.
* Participate in interdisciplinary case conferences and collaborative care meetings.
* Monitor member progress and adjust care plans as needed.
* Ensure compliance with Medi-Cal ECM program requirements, documentation standards, and reporting obligations.
* Perform other duties as assigned.