ECM Case Manager

Job Description

Posted Wednesday, March 4, 2026 at 11:00 AM

Position Summary:

Under the supervision of the Utilization Management Manager, the Case Manager is responsible for constructing a comprehensive care plan and providing a range of care coordination services; including but not limited to, monthly health interviews with patients, coordination with family members and caregivers, and working with community services to ensure access to care. The Case Manager is comfortable in providing guidance and completion of needs assessments, development of patient-focused care plans, periodic reassessments, and comprehensive service coordination (such as assisting with access challenges, developing relationships with service providers, and tracking interventions and outcomes).

In addition, the Case Manager will provide telephonic Care Management (non-face-to-face) services, as an extension of the clinical staff of SYHealth, managing patients with 2 or more diagnosed chronic conditions.

Essential Functions of the Job:

• Develop an individualized comprehensive plan of care integrating primary care and community support services to achieve the whole-person health goals designed with interventions to improve functional status, health status, or prevent decline.
• Identify and initiate referrals for social service programs; including financial, psychosocial, community and state supportive services integrating community social supports into the comprehensive care plan to include mitigating housing instability and homelessness.
• Provide a complete continuum of quality care through close communication with members via in-person or telephone interaction assisting clients in navigating health, behavioral health, and social services systems, and transitions of care; identify barriers to goals and support clients and caregivers through advocacy to ensure client needs and choices are fully represented and supported by their health care team.
• Review individual care plans and make monthly phone calls and/or in-person visits to CCM and ECM enrolled patients. These may include:
  • Assess current health status.
  • Medication reconciliation & compliance assessment, as appropriate.
  • Appointment reminders.
  • Appropriate patient education regarding the patient’s condition management at home/community.
  • Review orders, labs, consults, and associated documentation; as indicated by clinical providers.
  • Encourage and provide resources on preventative health services.
  • Thorough documentation in the patient’s electronic health record regarding the care plan reflecting outreach, communication, updated information, test results, social determinants, and any additional required documentation according to the patient’s care plan.
  • Manage the flow of information to/from provider’s office and/or community resources to the patient and appropriate caregivers.
• Manage caseloads according mandated program requirements to ensure compliance with timely completion of care planning, follow up activities, documentation and submission time frames, and all components of patient engagement.
• Prepares and submits productivity reports daily, weekly, and/or monthly by pre-determined deadlines; as required.
• Maintains a comprehensive care management structure: complete electronic care plan, perform care coordination, assist with transitions of care along with other care management services, record patient health information, and communicates timely key patient health information, and provides health promotion and additional services to help members with community and social services (such as housing, transportation, and food), as required.
• Utilizes the Primary Care Medical Home model to provide coordinated Team Care that addresses current diseases and facilitates inter-disciplinary management for preventative and health maintenance follow-up for patients enrolled in ECM.
• As required, meets with the clinic Care Team and other community resources to identify and implement actions for improving population management outcomes.
• Reinforces information given to the patient and/or family with handouts to improve patient self-management skills and communication.
• Acts as a point of contact for…