Lead care manager 

Monday to Friday 8AM - 5PM with 1hour unpaid break 

The Lead Care Manager is responsible for successfully engaging with a minimum of 25 members a day.
Leaving voicemails, members not being available, and members hanging up the phone do not count as
engagement. A successful engagement is defined as obtaining consent from the member, completing the
assessment, completing the care plan, and being able to provide case management services. The Lead Care
Manager works in collaboration and continuous partnership with chronically ill or “high-risk”members and
their family/caregiver(s), clinic/ hospital/specialty providers and staff, and community resources in a team
approach to:

• Coordinate with those individuals and/or entities to ensure a seamless experience for the member
and non-duplication of services.
• Engage eligible members.
• Oversee provision of ECM services and implementation of the care plan.
• Offer services where the member lives, seeks care, or finds most easily accessible and within the
Plan guidelines.
• Connect member to other social services and supports the member may need, including
transportation.
• Advocate on behalf of members with health care professionals.
• Use motivational interviewing, trauma-informed care, and harm-reduction approaches.
• Coordinate with hospital staff on discharge plans.
• Accompany member to office visits, as needed and according to the Plan guidelines.
• Monitor treatment adherence (including medication).
• Provide health promotion and self-management training
• Promote timely access to appropriate care
• Increase utilization of preventative care
• Reduce emergency room utilization and hospital readmissions
• Increase comprehension through culturally and linguistically appropriate education
• Create and promote adherence to a care plan, developed in coordination with the member, primary
care provider, and family/caregiver(s)

• Increase continuity of care by managing relationships with tertiary care providers, transitions-in-
care, and referrals

• Increase members’ ability for self-management and shared decision-making
• Connect members to relevant community resources to enhance member health and well-being,
increase member satisfaction, and reduce health care costs.
• Connect and follow up with members, family/caregiver(s), providers, and community resources via
face-to-face, secure email, phone calls, text messages, and other communications.
• Serve as the contact point, advocate, and informational resource for members, care team,
family/caregiver(s), payers, and community resources
• Work with members to plan and monitor care
• Assess member’s unmet health and social needs
• Develop a care plan with the member, family/caregiver(s), and providers (emergency plan, health
management plan, medical summary, and ongoing action plan, as appropriate)
• Monitor adherence to care plans, evaluate effectiveness, monitor member progress on
• time, and facilitate changes as needed.

• Create ongoing processes for members and family/caregiver(s) to determine and request the level
of care coordination support they desire at any given time.
• Facilitate members’ access to appropriate medical and specialty providers.
• Educate members and family/caregiver(s) about relevant community resources.
• Facilitate and attend meetings between members, family/caregiver(s), care team, payers, and
community resources, as needed
• Cultivate and support primary care and specialty provider co-management with timely
communication, inquiry, follow-up, and integration of information into the care plan regarding
transitions-in-care and referrals
• Provide Home Health Care
• Assist with the identification of “high-risk” members (the chronically ill and those with
• special health care needs), and add these to the member registry (or flag in EHR)
• Attend all Lead Care Manager training courses/webinars and meetings
• Provide feedback for the improvement of the ECM Program

• Offer services where the Member lives, seeks care, or finds most easily accessible and within Medi-
Cal Managed Care health plans (MCP) guidelines

• Engage eligible Members
• Arrange transportation
• Call Member to facilitate Member visit with the ECM Lead Care Manager
• Perform data analysis generated from internal legacy systems and provide insight to trends
identified in the analysis.
• Support implementation and monitor adoption of new workflows and performance as
• directed by the department’s leadership.
• Solicit voice of clinical team members in QI plan creation and train staff on QI methods when
needed.
• Utilize EHR and/or population management programs for data collection and report building.
• Drive to clinic locations as needed.
• Assist in the preparation of the Quality-of-Care reports
• Improve and drive Quality Improvement
• Develop policies, procedures, and protocols for the department using knowledge of Quality
Improvement principles, practices, and procedures.
• Work directly with the staff in establishing, refining, and implementing developed policies,
procedures, and protocols for use in the clinic.
• Assist with the tracking of clinical indicators on a monthly basis and reporting these measures to the
supervisor.
• Perform other duties as assigned.

QUALIFICATION REQUIREMENTS:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The
requirements below represent the required knowledge, skill, and/or ability. 

EDUCATION AND/OR EXPERIENCE:
• Bachelor’s or master’s Degree, certified case managers, social workers, or nurse
• 1 to 2 years’ experience in clinical or community resource settings; Care coordination and case
management
• Current CPR certification (if available) 
• TB test
• Minimum 1+ year(s) professional or personal experience supporting seniors, individuals with
disabilities, mental illnesses, or challenging behaviors

• Evidence of essential communication, education, and counseling skills
• Proficiency in communication technologies (email, cell phone, etc.)
• Highly organized with the ability to keep accurate notes and records
• Experience with health IT systems and reports is desirable
• local knowledge about and connections to community health care and
• social welfare resources are desirable
•
SKILL AND KNOWLEDGE REQUIREMENTS:
Must be fluent in Spanish and English
• Excellent analytical, problem-solving, and prioritization skills.
• Use statistical and graphic displays.
• Excellent verbal and written communication skills.
• High-level interpersonal skills. Able to work collaboratively and tactfully with multi-disciplinary and
diverse teams that may include employees, customers, and physicians.
• Effective computer skills, particularly Microsoft Office, Excel, PowerPoint, Publisher, Paint, Word,
etc.
• Work independently to complete assigned tasks.
• Team building
• Project Management
• Change Management
• Quality and Process improvement tools
• Project Execution