HATS - Health Advocacy Team Support

Enhanced Care Manager (ECM)

• Caseload Management: Maintain and manage a dedicated caseload of 35 to 40 members, ensuring regular contact and follow-up.
• Comprehensive Assessments: Conduct psychosocial, physical, and environmental assessments to identify barriers to care and wellness.
• Care Planning: Develop and implement individualized, culturally competent care plans that reflect member goals and clinical necessity.
• Monitoring & Evaluation: Regularly monitor care plan effectiveness, updating strategies based on member progress, clinical changes, or compliance updates.
• Discharge Planning: Coordinate hospital and skilled nursing facility (SNF) discharge planning to ensure a safe transition and continuity of care.

• System Navigation: Act as a primary advocate to help members navigate the complexities of Medi-Cal, CalAIM, and other public benefits.
• Wraparound Services: Identify, refer, and secure community-based resources, including housing, food security, and transportation.
• Care Integration: Collaborate and communicate effectively with medical providers, mental health specialists, social workers, and housing agencies to close gaps in care.
• Education: Provide health literacy coaching to members and their families regarding chronic disease management, behavioral health, and self-care.
  
  

• Documentation: Maintain meticulous, real-time documentation within the Electronic Health Record (EHR) in compliance with DHCS and county standards.
• Regulatory Adherence: Strict adherence to HIPAA, CalAIM, and organizational privacy policies.
• Professional Development: Participate in interdisciplinary team meetings and ongoing training as assigned by the Director of Operations.

• Education: Associate degree in a health-related or social services field required; Bachelor’s degree preferred.
• Experience: Minimum of 2 years of direct experience in healthcare coordination, social work, or community-based social services.
  
  

• Driver’s License: Valid California Driver’s License with a clean driving record and active auto insurance.
• Life Support: Current Basic Life Support (BLS) certification from the American Heart Association (AHA).
  
  

• Technical: Proficiency in Google Drives
• Interpersonal: Strong verbal and written communication skills; ability to build rapport with vulnerable populations.
• Operational: Exceptional time management and the ability to work independently in a field-based/hybrid environment.
  
  

• Hybrid Nature: Requires a mix of remote administrative work and frequent travel for in-person home visits, community meetings, and team gatherings.
• Travel: Must have access to a reliable vehicle and be willing to travel within the assigned territory. (Mileage reimbursement provided per IRS standards).
• Physical Demands: Ability to sit/stand for extended periods, operate a computer, and occasionally lift up to 15 lbs.