Enhanced Care Management Outreach

True Care is a trusted healthcare provider serving San Diego and Riverside counties, offering compassionate and comprehensive care to underserved communities. We are committed to making healthcare accessible to everyone, regardless of income or insurance status. With a focus on culturally sensitive, affordable services, True Care aims to improve the health of diverse communities. Our vision is to be the premier healthcare provider in the region, delivering exceptional patient experiences through innovative, integrated care.

Grant funded through Dec 31, 2026

• Provide Enhanced Care Management (ECM) services and implement Individualized Care Plans (ICPs) to patients with serious, complex, or chronic health problems or psychosocial issues.
• Conduct outreach to potential patients, including mobile outreach to community and field-based locations where individuals live, seek shelter, seek care, or find the most easily accessible within Managed Care Program (MCP) guidelines, to determine eligibility for services; document outreach attempts on a daily basis.
• Perform enrollment screening with eligible individuals and assist patients with enrollment in True Care programs.
• Collect and enter patient personal, medical, and statistical information into electronic health records (EHR) system to ensure effective coordination of care.
• Maintain a caseload of patients; perform frequent outreach through field visits, home visits, phone calls, and/or other electronic methods as appropriate to attain updates on patients' health status and provide effective coordination of care.
• Identifies goals for care management with patients; monitors patients' progress and modifies goals as appropriate.
• Facilitate patient access to appropriate medical and specialty providers.
• Connect patients to relevant community resources with the goal of enhancing patient health, well-being and increasing patient satisfaction.
• Schedule appointments according to clinical and scheduling guidelines.
• Document pertinent care management information (e.g., plans, interventions, goals).
• Participate in case conferences and periodic meetings as required.
• Engage with potential and eligible patients using principles of trauma-informed care and harm-reduction practices.

• High school diploma or equivalent.
• At least one (1) year of care coordination experience, or one (1) year of referrals experience.
• Bilingual in English and Spanish.
• Knowledge of medical terminology and care coordination.
• Computer proficiency, particularly with electronic health/medical record systems and the Microsoft Office suite, including Outlook and Word.

• Associate's degree in social work, human services, counseling, human relations, or a related field.

• Competitive Compensation
• Competitive Time Off
• Low-cost health, dental, vision & life insurance

Pay range for this role $21 to $29.40 on an hourly basis.

Pay transparency:
If you are hired at True Care, your salary will be determined based on factors such as education, knowledge, skills, and experience. In addition to those factors, we believe in the importance of pay equity and consider the internal equity of our current team members when determining an offer.

True Care is committed to a policy of Equal Employment Opportunity and will not discriminate against an applicant or employee on the basis of any characteristic protected by applicable federal, state, or local law. Our goal is to support all team members recruited or employed here.